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Poyekar S, Kapoor D. Pre-Liver Transplant Cardiac Evaluation-Demystifying the Heart Under Stress or Unclogging the Coronaries? J Clin Exp Hepatol 2025; 15:102448. [PMID: 40177698 PMCID: PMC11959372 DOI: 10.1016/j.jceh.2024.102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 10/21/2024] [Indexed: 04/05/2025] Open
Affiliation(s)
- Samriddhi Poyekar
- Associate Consultant, Transplant Medicine, Yashoda Hospital, Secunderabad, India
| | - Dharmesh Kapoor
- Senior Consultant- Hepatologist, Yashoda Hospital, Secunderabad, India
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2
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Gu C, Dong L, Chai L, Tong Z, Gao F, Ageno W, Romeiro FG, Qi X. Risk of Coronary Artery Disease in Patients with Liver Cirrhosis: A Systematic Review and Meta-analysis. J Clin Transl Hepatol 2025; 13:93-104. [PMID: 39917469 PMCID: PMC11797818 DOI: 10.14218/jcth.2024.00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 10/18/2024] [Accepted: 10/31/2024] [Indexed: 02/09/2025] Open
Abstract
BACKGROUND AND AIMS Coronary artery disease (CAD) is increasingly observed in patients with liver cirrhosis. However, data on the incidence and prevalence of CAD in cirrhotic patients are heterogeneous, and the association remains uncertain. In this study, we aimed to conduct a systematic review and meta-analysis to address these issues. METHODS PubMed, EMBASE, and Cochrane Library databases were searched. Incidence, prevalence, and factors associated with CAD were pooled using a random-effects model. Risk ratio (RR) and odds ratio (OR), with their 95% confidence interval (CI), were calculated to evaluate differences in CAD incidence and prevalence between patients with and without liver cirrhosis. RESULTS Fifty-one studies were included. The pooled incidences of CAD, acute coronary syndromes, and myocardial infarction (MI) were 2.28%, 2.02%, and 1.80%, respectively. Liver cirrhosis was not significantly associated with CAD incidence (RR = 0.77; 95% CI = 0.46-1.28) or MI (RR = 0.87; 95% CI = 0.49-1.57). The pooled prevalence of CAD, acute coronary syndromes, and MI was 18.87%, 12.54%, and 6.12%, respectively. Liver cirrhosis was not significantly associated with CAD prevalence (OR = 1.29; 95% CI = 0.83-2.01) or MI (OR = 0.58; 95% CI = 0.28-1.22). Non-alcoholic steatohepatitis, hepatitis C virus, advanced age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking history, and family history of CAD were significantly associated with CAD in cirrhotic patients. CONCLUSIONS CAD is common in cirrhotic patients, but cirrhosis itself may not be associated with an increased CAD risk. In addition to traditional risk factors, non-alcoholic steatohepatitis and hepatitis C virus infection are also associated with CAD presence in cirrhotic patients.
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Affiliation(s)
- Chunru Gu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
| | - Liyan Dong
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
| | - Lu Chai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Zhenhua Tong
- Section of Medical Service, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
| | - Fangbo Gao
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Teaching Hospital of the China Medical University), Shenyang, Liaoning, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, Liaoning, China
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Chan KE, Ong EYH, Chung CH, Ong CEY, Koh B, Tan DJH, Lim WH, Yong JN, Xiao J, Wong ZY, Syn N, Kaewdech A, Teng M, Wang JW, Chew N, Young DY, Know A, Siddiqui MS, Huang DQ, Tamaki N, Wong VWS, Mantzoros CS, Sanyal A, Noureddin M, Ng CH, Muthiah M. Longitudinal Outcomes Associated With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Meta-analysis of 129 Studies. Clin Gastroenterol Hepatol 2024; 22:488-498.e14. [PMID: 37775028 DOI: 10.1016/j.cgh.2023.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND & AIMS The progression of metabolic dysfunction-associated steatotic liver disease (MASLD) has been found to manifest in a series of hepatic and extrahepatic complications. A comprehensive meta-analysis of the longitudinal outcomes associated with MASLD has yet to be conducted. METHODS To investigate the longitudinal outcomes associated with MASLD, Medline and Embase databases were searched to identify original studies that evaluated the longitudinal risks of incident clinical outcomes among MASLD patients compared with non-MASLD individuals. DerSimonian Laird random-effects meta-analysis was performed. Pooled effect estimates were calculated, and heterogeneity among studies was evaluated. RESULTS One hundred twenty-nine studies were included in the meta-analysis. Meta-analysis revealed a significant increase in the risk of cardiovascular outcomes (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.27-1.60; P < .01), various metabolic outcomes such as incident hypertension (HR, 1.75; 95% CI, 1.46-2.08; P < .01), diabetes (HR, 2.56; 95% CI, 2.10-3.13; P < .01), pre-diabetes (HR, 1.69; 95% CI, 1.22-2.35; P < .01), metabolic syndrome (HR, 2.57; 95% CI, 1.13-5.85; P = .02), chronic kidney disease (HR, 1.38; 95% CI, 1.27-1.50; P < .01), as well as all cancers (HR, 1.54; 95% CI, 1.35-1.76; P < .01) among MASLD patients compared with non-MASLD individuals. By subgroup analysis, MASLD patients with advanced liver disease (HR, 3.60; 95% CI, 2.10-6.18; P < .01) were also found to be associated with a significantly greater risk (P = .02) of incident diabetes than those with less severe MASLD (HR, 1.63; 95% CI, 1.0-2.45; P = .02) when compared with non-MASLD. CONCLUSIONS The present study emphasizes the association between MASLD and its clinical outcomes including cardiovascular, metabolic, oncologic, and other outcomes. The multisystemic nature of MASLD found in this analysis requires treatment targets to reduce systemic events and end organ complications.
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Affiliation(s)
- Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Elden Yen Hng Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Charlotte Hui Chung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christen En Ya Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhen Yu Wong
- Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Margaret Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Jiong-Wei Wang
- Department of Surgery, Cardiovascular Research Institute (CVRI), Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Nanomedicine Translational Research Programme, Centre for Nanomedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Dan Yock Young
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Alfred Know
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore; Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University Hospital Singapore, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Q Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Christos S Mantzoros
- Division of Endocrinology, Department of Medicine, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arun Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | | | - Cheng Han Ng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore; National University Centre for Organ Transplantation, National University Health System, Singapore.
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Zhu B, Wu H, Li KS, Eisa-Beygi S, Singh B, Bielenberg DR, Huang W, Chen H. Two sides of the same coin: Non-alcoholic fatty liver disease and atherosclerosis. Vascul Pharmacol 2024; 154:107249. [PMID: 38070759 DOI: 10.1016/j.vph.2023.107249] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 02/03/2024]
Abstract
The prevalence of non-alcoholic fatty liver disease (NAFLD) and atherosclerosis remain high, which is primarily due to widespread adoption of a western diet and sedentary lifestyle. NAFLD, together with advanced forms of this disease such as non-alcoholic steatohepatitis (NASH) and cirrhosis, are closely associated with atherosclerotic-cardiovascular disease (ASCVD). In this review, we discussed the association between NAFLD and atherosclerosis and expounded on the common molecular biomarkers underpinning the pathogenesis of both NAFLD and atherosclerosis. Furthermore, we have summarized the mode of function and potential clinical utility of existing drugs in the context of these diseases.
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Affiliation(s)
- Bo Zhu
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Hao Wu
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Kathryn S Li
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Shahram Eisa-Beygi
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Bandana Singh
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Diane R Bielenberg
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America
| | - Wendong Huang
- Department of Diabetes Complications and Metabolism, Arthur Riggs Diabetes and Metabolic Research Institute, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, United States of America
| | - Hong Chen
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States of America.
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Mechelinck M, Hein M, Kupp C, Braunschweig T, Helmedag MJ, Klinkenberg A, Habigt MA, Klinge U, Tolba RH, Uhlig M. Experimental Liver Cirrhosis Inhibits Restenosis after Balloon Angioplasty. Int J Mol Sci 2023; 24:11351. [PMID: 37511114 PMCID: PMC10379020 DOI: 10.3390/ijms241411351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The effect of liver cirrhosis on vascular remodeling in vivo remains unknown. Therefore, this study investigates the influence of cholestatic liver cirrhosis on carotid arterial remodeling. A total of 79 male Sprague Dawley rats underwent bile duct ligation (cirrhotic group) or sham surgery (control group) and 28 days later left carotid artery balloon dilatation; 3, 7, 14 and 28 days after balloon dilatation, the rats were euthanized and carotid arteries were harvested. Histological sections were planimetrized, cell counts determined, and systemic inflammatory parameters measured. Up to day 14 after balloon dilatation, both groups showed a comparable increase in neointima area and degree of stenosis. By day 28, however, both values were significantly lower in the cirrhotic group (% stenosis: 20 ± 8 vs. 42 ± 10, p = 0.010; neointimal area [mm2]: 0.064 ± 0.025 vs. 0.138 ± 0.025, p = 0.024). Simultaneously, cell density in the neointima (p = 0.034) and inflammatory parameters were significantly higher in cirrhotic rats. This study demonstrates that cholestatic liver cirrhosis in rats substantially increases neointimal cell consolidation between days 14 and 28. Thereby, consolidation proved important for the degree of stenosis. This may suggest that patients with cholestatic cirrhosis are at lower risk for restenosis after coronary intervention.
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Affiliation(s)
- Mare Mechelinck
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Carolin Kupp
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Till Braunschweig
- Department of Pathology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Marius J Helmedag
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Axel Klinkenberg
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Moriz A Habigt
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Uwe Klinge
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - René H Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Moritz Uhlig
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
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Khandait H, Jaiswal V, Hanif M, Shrestha AB, Iturburu A, Shah M, Ishak A, Garimella V, Ang SP, Mathew M. Percutaneous Coronary Intervention Outcomes in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10030092. [PMID: 36975856 PMCID: PMC10059068 DOI: 10.3390/jcdd10030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/01/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
There is a paucity of data and minimal literature on outcomes of percutaneous coronary intervention (PCI) among liver cirrhosis patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the clinical outcomes among liver cirrhosis patients post-PCI. We conducted a comprehensive literature search in the PubMed, Embase, Cochrane, and Scopus databases for relevant studies. Effect sizes were pooled using the DerSimonian and Laird random-effects model as an odds ratio (OR) with 95% confidence intervals (CI). A total of 3 studies met the inclusion criteria, providing data from 10,705,976 patients. A total of 28,100 patients were in the PCI + Cirrhosis group and 10,677,876 patients were in the PCI-only group. The mean age of patients with PCI + Cirrhosis and PCI alone was 63.45 and 64.35 years. The most common comorbidity was hypertension among the PCI + Cirrhosis group compared with PCI alone (68.15% vs. 73.6%). Cirrhosis patients post-PCI were had higher rates of in-hospital mortality (OR, 4.78 (95%CI: 3.39–6.75), p < 0.001), GI bleeding (OR, 1.91 (95%CI:1.83–1.99), p < 0.001, I2 = 0%), stroke (OR, 2.48 (95%CI:1.68–3.66), p < 0.001), AKI (OR, 3.66 (95%CI: 2.33–6.02), p < 0.001), and vascular complications (OR, 1.50 (95%CI: 1.13–1.98), p < 0.001) compared with the PCI group without cirrhosis. Patients with cirrhosis are at a high risk for mortality and adverse outcomes post-PCI procedure compared to the PCI-only group of patients.
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Affiliation(s)
| | - Vikash Jaiswal
- Department of Research, JCCR Cardiology Research, Varanasi 221005, India
- Correspondence:
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | | | - Alisson Iturburu
- Department of Medicine, Universidad de Guayaquil, Guayas 090514, Ecuador
| | - Maitri Shah
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Angela Ishak
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Vamsi Garimella
- Department of Internal Medicine, University of Miami (Holy Cross), Miami, FL 33136, USA
| | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, Toms River, NJ 08755, USA
| | - Midhun Mathew
- Trinitas Regional Medical Center/RWJ Barnabas Health, Elizabeth, NJ 07202, USA
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Doycheva I, Izzy M, Watt KD. Cardiovascular assessment before liver transplantation. CARDIO-HEPATOLOGY 2023:309-326. [DOI: 10.1016/b978-0-12-817394-7.00005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Ndrepepa G, Holdenrieder S, Kastrati A. De Ritis ratio and long-term major cardiovascular adverse events in patients undergoing elective percutaneous coronary intervention. Eur J Clin Invest 2022; 53:e13942. [PMID: 36575818 DOI: 10.1111/eci.13942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The association of aspartate aminotransferase to alanine aminotransferase ratio (De Ritis ratio) with clinical outcomes in patients with chronic coronary syndromes (CCS) remains unclear. This study aims to assess the association of De Ritis ratio with adverse cardiovascular events in patients with CCS. MATERIALS AND METHODS The study included 5020 patients with CCS undergoing percutaneous coronary intervention. Patients were categorized into groups according to tertiles of the De Ritis ratio: tertile 1 (De Ritis ratio: <.75; n = 1688 patients), tertile 2 (De Ritis ratio: .75-1.08; n = 1666 patients) and tertile 3 (De Ritis ratio: >1.08; n = 1666 patients). The primary endpoint was 3-year mortality. RESULTS At 3 years, there were 384 deaths, 176 myocardial infarctions and 61 strokes. In groups with De Ritis in the 1st, 2nd and 3rd tertiles, deaths occurred in 5.0%, 7.5% and 14.5% of the patients, respectively (adjusted hazard ratio = 1.09, 95% confidence interval [1.06-1.12], p < .001); myocardial infarctions occurred in 2.6%, 3.5% and 5.1% of the patients, respectively (p < .001); strokes occurred in 1.0%, 1.2% and 1.9% of the patients, respectively (p = .030); bleeding at 30 days (n = 112) occurred in 1.4%, 1.6% and 3.7% of the patients, respectively (p < .001). The C-statistic of the Cox proportional hazards model for all-cause mortality with baseline data without the De Ritis ratio was .815 [.794-.836] and .818 [.797-.838] after the inclusion of the De Ritis ratio (delta C-statistic = .003; p = .005). CONCLUSIONS In patients with CCS undergoing percutaneous coronary intervention, an elevated De Ritis ratio was associated with long-term major adverse cardiovascular events.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Stefan Holdenrieder
- Institut für Laboratoriumsmedizin, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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10
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Kozlik A, Wiseman K, Upadhyaya VD, Sharma A, Chatterjee S. Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature). Am J Cardiol 2022; 185:94-99. [DOI: 10.1016/j.amjcard.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
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Esteban JPG, Asgharpour A. Evaluation of liver transplant candidates with non-alcoholic steatohepatitis. Transl Gastroenterol Hepatol 2022; 7:24. [PMID: 35892057 PMCID: PMC9257540 DOI: 10.21037/tgh.2020.03.04] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 02/03/2020] [Indexed: 11/07/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is anticipated to become the leading indication for liver transplantation (LT) in the United States in the near future. LT is indicated in patients with NASH-related cirrhosis who have medically refractory hepatic decompensation, synthetic dysfunction, and hepatocellular carcinoma (HCC) meeting certain criteria. The objective of LT evaluation is to determine which patient will derive the most benefit from LT with the least risk, thus maximizing the societal benefits of a limited resource. LT evaluation is a multidisciplinary undertaking involving several specialists, assessment tools, and diagnostic testing. Although the steps involved in LT evaluation are relatively similar across different liver diseases, patients with NASH-related cirrhosis have unique demographic and clinical features that affect transplant outcomes and influence their LT evaluation. LT candidates with NASH should be assessed for metabolic syndrome and obesity, malnutrition and sarcopenia, frailty, and cardiovascular disease. Interventions that treat cardiometabolic co-morbidities and improve patients' nutrition and functionality should be considered in order to improve patient outcomes in the waitlist and after LT.
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Affiliation(s)
- James Philip G Esteban
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amon Asgharpour
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Gîrleanu I, Trifan A, Huiban L, Muzîca C, Petrea OC, Sîngeap AM, Cojocariu C, Chiriac S, Cuciureanu T, Costache II, Stanciu C. Ischemic Heart Disease and Liver Cirrhosis: Adding Insult to Injury. Life (Basel) 2022; 12:1036. [PMID: 35888123 PMCID: PMC9315506 DOI: 10.3390/life12071036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/13/2022] Open
Abstract
The link between heart and liver cirrhosis was recognized decades ago, although much data regarding atherosclerosis and ischemic heart disease are still missing. Ischemic heart disease or coronary artery disease (CAD) and liver cirrhosis could be associated with characteristic epidemiological and pathophysiological features. This connection determines increased rates of morbidity and all-cause mortality in patients with liver cirrhosis. In the era of a metabolic syndrome and non-alcoholic fatty liver disease pandemic, primary prevention and early diagnosis of coronary artery disease could improve the prognosis of liver cirrhosis patients. This review outlines a summary of the literature regarding prevalence, risk assessment and medical and interventional treatment options in this particular population. A collaborative heart-liver team-based approach is imperative for critical management decisions for patients with CAD and liver cirrhosis.
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Affiliation(s)
- Irina Gîrleanu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Anca Trifan
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Laura Huiban
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Cristina Muzîca
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Oana Cristina Petrea
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Ana Maria Sîngeap
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Camelia Cojocariu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Stefan Chiriac
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Tudor Cuciureanu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Irina Iuliana Costache
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Cardiology Department, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Carol Stanciu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
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13
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Kassab K, Doukky R. Cardiac imaging for the assessment of patients being evaluated for liver transplantation. J Nucl Cardiol 2022; 29:1078-1090. [PMID: 33825142 DOI: 10.1007/s12350-021-02591-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
Cardiac risk assessment prior to liver transplantation has become widely accepted. With the emergence of nonalcoholic steatohepatitis among the leading causes of end-stage liver disease and the steady rise of the age of liver transplant recipients, the burden of cardiovascular diseases has markedly increased in this population. Selecting appropriate liver transplant candidates is crucial due to the increasing demand for scarce donor organs. The use of noninvasive cardiac imaging for pre-operative assessment of the cardiovascular status of liver transplant recipients has been on the rise, yet the optimal assessment strategy remains an area of active debate. In this review, we examine the relevant literature pertaining to the diagnostic and prognostic applications of noninvasive cardiac imaging in this population. We also propose a simple literature-based evaluation algorithm for CAD surveillance in liver transplant candidates.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Cook County Health, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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14
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Dangl M, Eisenberg T, Grant JK, Vincent L, Colombo R, Sancassani R, Braghiroli J, Martin P, Vianna R, Nicolau-Raducu R, Mendoza C. A comprehensive review of coronary artery disease in patients with end-stage liver disease. Transplant Rev (Orlando) 2022; 36:100709. [DOI: 10.1016/j.trre.2022.100709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/02/2022] [Accepted: 05/17/2022] [Indexed: 11/16/2022]
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15
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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16
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Ahmed T, Grigorian AY, Messerli AW. Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis. Am J Cardiovasc Drugs 2022; 22:55-67. [PMID: 34050893 DOI: 10.1007/s40256-021-00478-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/12/2022]
Abstract
Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.
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17
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The Change in Metabolic Syndrome Status and the Risk of Nonviral Liver Cirrhosis. Biomedicines 2021; 9:biomedicines9121948. [PMID: 34944764 PMCID: PMC8698513 DOI: 10.3390/biomedicines9121948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Nonalcoholic fatty liver disease is considered to be the hepatic component of metabolic syndrome (MetS). However, the association between changes in MetS status and the risk of liver cirrhosis (LC) has not been investigated to date. This study assessed the association between changes in MetS and subsequent nonviral LC development. Methods: Data were obtained from the Korean National Health Insurance Service. Individuals who participated in health screenings from both 2009 to 2010 and 2011 to 2012 were included. The primary outcome was LC development according to the static and dynamic MetS status. Subjects were stratified into four groups according to the change in MetS status observed from the two-year interval screening (2009–2011). Cox regression analysis was used to examine the hazard ratios of LC. Results: During a median of 7.3 years of follow-up, 24,923 incident LC cases developed among 5,975,308 individuals. After adjusting for age, sex, smoking, alcohol, regular exercise, and body mass index, the adjusted hazard ratios (95% confidence intervals) for LC development were 1.39 (1.33–1.44) for the MetS-Developed group, 1.32 (1.26–1.37) for the MetS-Recovered group, and 1.51 (1.45–1.56) for the MetS-Sustained group, relative to the MetS-Free group. Stratified analyses according to age, sex, smoking, alcohol intake, exercise, diabetes mellitus, hypertension, dyslipidemia, and chronic kidney disease showed similar results. Conclusions: Both static and dynamic MetS status are independent risk factors for LC development. The risk of LC was the highest in people with sustained MetS and was lower in the MetS-Recovered group than in the MetS-Sustained group. These results suggest that improving a person’s MetS status may be helpful in preventing LC.
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18
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Mechelinck M, Peschel M, Habigt MA, Kroy D, Lehrke M, Helmedag MJ, Rossaint R, Barton M, Hein M. Serum from Patients with Severe Alcoholic Liver Cirrhosis Inhibits Proliferation and Migration of Human Coronary Artery Smooth Muscle Cells. J Clin Med 2021; 10:jcm10235471. [PMID: 34884173 PMCID: PMC8658341 DOI: 10.3390/jcm10235471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 12/20/2022] Open
Abstract
Liver cirrhosis has been associated with an increased risk of coronary artery disease and clinical complications following percutaneous coronary revascularization. The present study is based on the hypothesis that cirrhosis may influence intimal hyperplasia following PCI. Sera from 10 patients with alcoholic liver cirrhosis and 10 age-matched healthy controls were used to stimulate cultured human coronary artery smooth muscle cells (HCASMC) for 48 h. HCASMC proliferation, migration, gene expression and apoptosis were investigated. Serum concentrations of growth factors and markers of liver function were also determined in patients and healthy controls. Treatment of HCASMC with patient sera reduced cell proliferation and migration (p < 0.05 vs. healthy controls), whereas apoptosis was unaffected (p = 0.160). Expression of genes associated with a synthetic vascular smooth muscle cell phenotype was decreased in cells stimulated with serum from cirrhotic patients (RBP1, p = 0.001; SPP1, p = 0.003; KLF4, p = 0.004). Platelet-derived growth factor-BB serum concentrations were lower in patients (p = 0.001 vs. controls). The results suggest the presence of circulating factors in patients with alcoholic liver cirrhosis affecting coronary smooth muscle cell growth. These findings may have implications for clinical outcomes following percutaneous coronary revascularization in these patients.
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Affiliation(s)
- Mare Mechelinck
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.M.); (M.P.); (M.A.H.); (R.R.)
| | - Miriam Peschel
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.M.); (M.P.); (M.A.H.); (R.R.)
| | - Moriz A. Habigt
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.M.); (M.P.); (M.A.H.); (R.R.)
| | - Daniela Kroy
- Department of Internal Medicine III, Gastroenterology, Metabolic Diseases and Intensive Care, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany;
| | - Michael Lehrke
- Department of Internal Medicine I, Cardiology, Angiology and Internal Intensive Care Medicine, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany;
| | - Marius J. Helmedag
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany;
| | - Rolf Rossaint
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.M.); (M.P.); (M.A.H.); (R.R.)
| | - Matthias Barton
- Molecular Internal Medicine, University of Zürich, 8057 Zürich, Switzerland;
- Andreas Grüntzig Foundation, 8001 Zürich, Switzerland
| | - Marc Hein
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany; (M.M.); (M.P.); (M.A.H.); (R.R.)
- Correspondence:
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19
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Barman PM, VanWagner LB. Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions. Hepatology 2021; 73:2564-2576. [PMID: 33219576 PMCID: PMC8220582 DOI: 10.1002/hep.31647] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/25/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
In the changing landscape of liver transplantation (LT), we are now evaluating older and sicker patients with more cardiovascular comorbidities, and the spectrum of cardiovascular disease is uniquely physiologically impacted by end-stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in LT recipients, and the pretransplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications before LT is paramount to guide allocation of limited health care resources and to improve both short-term and long-term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end-stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end-stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in LT, evaluate the current evidence for surgery-related, short-term and long-term cardiac risk assessment in LT candidates, propose an evidence-based testing algorithm, and highlight specific gaps in knowledge and current controversies, identifying areas for future research.
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Affiliation(s)
- Pranab M. Barman
- Department of Medicine-Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA
| | - Lisa B. VanWagner
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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20
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Tiwari N, Margapuri J, Katamreddy A, Jubbal S, Madan N. Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 32:100714. [PMID: 33521238 PMCID: PMC7820133 DOI: 10.1016/j.ijcha.2021.100714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022]
Abstract
Background The incidence of coronary artery disease (CAD) in Liver transplant (LT) patients is much higher than prior estimates and the morbidity and mortality are significant in this group of patients. Coronary angiography is the gold standard for detection of CAD, a non-invasive test that allows appropriate risk stratification would be preferred. In this systematic review and meta-analysis, we sought to assess the pooled diagnostic accuracy of various noninvasive cardiac imaging tests in detecting CAD in patients listed for LT. Methods We performed a systematic review and meta-analysis of studies comparing sensitivity and specificity of non-invasive tests to that of coronary angiography in diagnosing coronary artery disease in patients undergoing liver transplantation. Results Five studies (616 participants) evaluated myocardial perfusion imaging (MPI); five studies (1243 participants) dobutamine stress echocardiography (DSE); and three (87 participants), other tests. MPI had a pooled sensitivity of 0.62 (95% CI 0.37, 0.83), specificity of 0.60 (95% CI 0.39, 0.79), diagnostic odds ratio (DOR) of 2.5 (95% CI 1.7, 5.64) and Area under the curve (AUC) 0.649. DSE had a pooled sensitivity of 0.25 (95%CI 0.09, 0.51), specificity of 0.68 (95% CI 0.44, 0.84) and DOR of 0.7 (95% CI 0.12, 3.84). Conclusions Our results show that both MPI and DSE are not effective screening tools for detecting CAD in patients with end-stage liver disease (ESLD). Future studies are needed to evaluate the role of real-time myocardial contrast echocardiography (RTMCE) and coronary artery calcium score (CAC) with coronary CT angiography in patients with ESLD.
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Affiliation(s)
- Nidhish Tiwari
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Adarsh Katamreddy
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandeep Jubbal
- University of Massachusetts Medical School, Worcester, MA, USA
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21
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Abstract
Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.
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22
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Steggerda JA, Mahendraraj K, Todo T, Noureddin M. Clinical considerations in the management of non-alcoholic steatohepatitis cirrhosis pre- and post-transplant: A multi-system challenge. World J Gastroenterol 2020; 26:4018-4035. [PMID: 32821068 PMCID: PMC7403794 DOI: 10.3748/wjg.v26.i28.4018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/07/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is the most common chronic liver disease worldwide, and the fastest growing indication for liver transplantation in the United States. NASH is now the leading etiology for liver transplantation in women, the second leading indication for men, and the most common cause amongst recipients aged 65 years and older. Patients with end-stage liver disease related to NASH represent a unique and challenging patient population due the high incidence of associated comorbid diseases, including obesity, type 2 diabetes (T2D), and hypertension. These challenges manifest in the pre-liver transplantation period with increased waitlist times and waitlist mortality. Furthermore, these patients carry considerable risk of morbidity and mortality both before after liver transplantation, with high rates of T2D, cardiovascular disease, chronic kidney disease, poor nutrition, and disease recurrence. Successful transplantation for these patients requires identification and management of their comorbidities in the face of liver failure. Multidisciplinary evaluations include a thorough pre-transplant workup with a complete cardiac evaluation, control of diabetes, nutritional support, and even, potentially, consultation with a bariatric surgeon. This article provides a comprehensive review of the conditions and challenges facing patients with NASH cirrhosis undergoing liver transplantation and provides recommendations for evaluation and management to optimize them before liver transplantation to produce successful outcomes.
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Affiliation(s)
- Justin A Steggerda
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Krishnaraj Mahendraraj
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Tsuyoshi Todo
- Department of Surgery, Division of Transplantation, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Mazen Noureddin
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
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23
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Cremonese C, Schierwagen R, Uschner FE, Torres S, Tyc O, Ortiz C, Schulz M, Queck A, Kristiansen G, Bader M, Sauerbruch T, Weiskirchen R, Walther T, Trebicka J, Klein S. Short-Term Western Diet Aggravates Non-Alcoholic Fatty Liver Disease (NAFLD) With Portal Hypertension in TGR(mREN2)27 Rats. Int J Mol Sci 2020; 21:E3308. [PMID: 32392802 PMCID: PMC7246932 DOI: 10.3390/ijms21093308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/14/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is gaining in importance and is linked to obesity. Especially, the development of fibrosis and portal hypertension in NAFLD patients requires treatment. Transgenic TGR(mREN2)27 rats overexpressing mouse renin spontaneously develop NAFLD with portal hypertension but without obesity. This study investigated the additional role of obesity in this model on the development of portal hypertension and fibrosis. Obesity was induced in twelve-week old TGR(mREN2)27 rats after receiving Western diet (WD) for two or four weeks. Liver fibrosis was assessed using standard techniques. Hepatic expression of transforming growth factor-β1 (TGF-β1), collagen type Iα1, α-smooth muscle actin, and the macrophage markers Emr1, as well as the chemoattractant Ccl2, interleukin-1β (IL1β) and tumor necrosis factor-α (TNFα) were analyzed. Assessment of portal and systemic hemodynamics was performed using the colored microsphere technique. As expected, WD induced obesity and liver fibrosis as confirmed by Sirius Red and Oil Red O staining. The expression of the monocyte-macrophage markers, Emr1, Ccl2, IL1β and TNFα were increased during feeding of WD, indicating infiltration of macrophages into the liver, even though this increase was statistically not significant for the EGF module-containing mucin-like receptor (Emr1) mRNA expression levels. Of note, portal pressure increased with the duration of WD compared to animals that received a normal chow. Besides obesity, WD feeding increased systemic vascular resistance reflecting systemic endothelial and splanchnic vascular dysfunction. We conclude that transgenic TGR(mREN2)27 rats are a suitable model to investigate NAFLD development with liver fibrosis and portal hypertension. Tendency towards elevated expression of Emr1 is associated with macrophage activity point to a significant role of macrophages in NAFLD pathogenesis, probably due to a shift of the renin-angiotensin system towards a higher activation of the classical pathway. The hepatic injury induced by WD in TGR(mREN2)27 rats is suitable to evaluate different stages of fibrosis and portal hypertension in NAFLD with obesity.
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Affiliation(s)
- Carla Cremonese
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Robert Schierwagen
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Frank Erhard Uschner
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Sandra Torres
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Olaf Tyc
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Cristina Ortiz
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Martin Schulz
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Alexander Queck
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
| | - Glen Kristiansen
- Institute for Pathology, University of Bonn, 53127 Bonn, Germany;
| | - Michael Bader
- Max Delbrück Center for Molecular Medicine, 13092 Berlin, Germany;
| | - Tilman Sauerbruch
- Department of Internal Medicine I, University Hospital of Bonn, 53127 Bonn, Germany;
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), RWTH University Hospital Aachen, 52074 Aachen, Germany;
| | - Thomas Walther
- Department of Pharmacology and Therapeutics, University College Cork, T12 YN60 Cork, Ireland;
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, 17489 Greifswald, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
- Institute for Bioengineering of Catalonia, 08028 Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure, 08021 Barcelona, Spain
- Faculty of Health Sciences, University of Southern Denmark, 5000 Odense, Denmark
| | - Sabine Klein
- Department of Internal Medicine I, Goethe University Frankfurt, 60323 Frankfurt, Germany; (C.C.); (R.S.); (F.E.U.); (S.T.); (O.T.); (C.O.); (M.S.); (A.Q.); (S.K.)
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24
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Lu DY, Steitieh D, Feldman DN, Cheung JW, Wong SC, Halazun H, Halazun KJ, Amin N, Wang J, Chae J, Wilensky RL, Kim LK. Impact Of Cirrhosis On 90-Day Outcomes After Percutaneous Coronary Intervention (from A Nationwide Database). Am J Cardiol 2020; 125:1295-1304. [PMID: 32145896 DOI: 10.1016/j.amjcard.2020.01.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/24/2020] [Accepted: 01/29/2020] [Indexed: 01/16/2023]
Abstract
Patients with cirrhosis often have concomitant coronary artery disease and require percutaneous coronary intervention (PCI). PCI in cirrhotics can be associated with significant risks due to thrombocytopenia, possible coagulopathies, bleeding, and renal failure. Longer term risks of PCI in cirrhotics have not been well studied. Our study seeks to evaluate the 90-day outcomes of PCI in patients with cirrhosis. Patients receiving PCI were identified from the Nationwide Readmissions Database from 2010 to 2014 and stratified by the presence of co-morbid cirrhosis. The total mortality during index admission and 90-day readmissions as well as the readmissions rate were examined. Adverse events including bleeding, stroke, kidney injury, and vascular complications were also compared. Patients with cirrhosis had a significantly higher number of co-morbidities. The cirrhosis group had a higher overall 90-day mortality (10.3% vs 2.5%, p < 0.01), including during the index hospitalization (7.0% vs 1.8%, p < 0.01), as well as a higher 90-day readmission rate (38.2% vs 20.2%, p < 0.01). Patients with cirrhosis also had higher frequencies of overall 90-day adverse events (44.7% vs 17.7%, p < 0.01), including gastrointestinal bleeding (15.3% vs 2.7%, p < 0.01) and acute kidney injury (28.4% vs 10.1%, p < 0.01). In conclusion, patients with cirrhosis face a significantly higher risk of adverse outcomes including mortality, readmissions, and adverse events in the 90 days after hospitalization for PCI compared with the general population.
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Affiliation(s)
- Daniel Y Lu
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
| | - Diala Steitieh
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Dmitriy N Feldman
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Jim W Cheung
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - S Chiu Wong
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Hadi Halazun
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Karim J Halazun
- Division of Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Nivee Amin
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Joseph Wang
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - John Chae
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Robert L Wilensky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Peensylvania
| | - Luke K Kim
- Weill Cornell Cardiovascular Outcomes Research Group (CORG), Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
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25
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Samji NS, Heda R, Kovalic AJ, Satapathy SK. Similarities and Differences Between Nonalcoholic Steatohepatitis and Other Causes of Cirrhosis. Gastroenterol Clin North Am 2020; 49:151-164. [PMID: 32033761 DOI: 10.1016/j.gtc.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Nonalcoholic fatty liver disease includes a spectrum of liver disorders that range from simple steatosis to nonalcoholic steatohepatitis (NASH), fibrosis, and cirrhosis. Risk factors such as obesity, hypertension, hyperlipidemia, chronic kidney disease, and smoking status increase risk of progression to cirrhosis among patients with NASH. Cirrhosis derived from non-NASH causes may share similar features with patients with NASH but embody distinct pathogenetic mechanisms, genetic associations, prognosis, and outcomes. This article discusses in detail the comparison of clinical, genetic, and outcome characteristics between patients with NASH cirrhosis as opposed to alternative causes of chronic liver disease.
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Affiliation(s)
- Naga Swetha Samji
- Tenova Cleveland Hospital, 2305 Chambliss Avenue Northwest, Cleveland, TN 37311, USA
| | - Rajiv Heda
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN 38163, USA
| | - Alexander J Kovalic
- Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Sanjaya K Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine/Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA.
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26
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Lu DY, Saybolt MD, Kiss DH, Matthai WH, Forde KA, Giri J, Wilensky RL. One-Year Outcomes of Percutaneous Coronary Intervention in Patients with End-Stage Liver Disease. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820901491. [PMID: 32030068 PMCID: PMC6977100 DOI: 10.1177/1179546820901491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/01/2020] [Indexed: 12/18/2022]
Abstract
Background: Patients with cirrhosis and coronary artery disease (CAD) are at high risk
for morbidity during surgical revascularization so they are often referred
for complex percutaneous coronary intervention (PCI). Percutaneous coronary
intervention in the cirrhotic population also has inherent risks; however,
quantifiable data on long-term outcomes are lacking. Methods: Patients with angiographically significant CAD and cirrhosis were identified
from the catheterization lab databases of the University of Pennsylvania
Health System between 2007 and 2015. Outcomes were obtained from the medical
record and telephonic contact with patients/families. Results: Percutaneous coronary intervention was successfully performed in 42 patients
(51 PCIs). Twenty-nine patients with significant CAD were managed medically
(36 angiograms). The primary outcome (a composite of mortality, subsequent
revascularization, and myocardial infarction) was not significantly
different between the 2 groups during a follow-up period at 1 year (PCI:
50%, Control: 40%, P = .383). In the PCI group, a composite
adverse outcome rate that included acute kidney injury (AKI), severe bleed,
and peri-procedural stroke was elevated (40%), with severe bleeding
occurring after 23% of PCI events and post-procedural AKI occurring after
26% of events. The medical management group had significantly fewer total
matched adverse outcomes (17% vs 40% in the PCI group,
P = .03), with severe bleeding occurring after 11% of
events and AKI occurring after 6% of events. Increased risk of adverse
events following PCI was associated with severity of liver disease by
Child-Pugh class. Conclusions: Percutaneous coronary intervention in patients with cirrhosis is associated
with an elevated risk of adverse events, including severe bleeding and
AKI.
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Affiliation(s)
- Daniel Y Lu
- New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY, USA
| | - Matthew D Saybolt
- Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Daniel H Kiss
- Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, USA
| | - William H Matthai
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Kimberly A Forde
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay Giri
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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27
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of the metabolic syndrome (MetS) and comprises one of the largest health threats of the twenty-first century. In this chapter, we review the current state of knowledge of NAFLD and underline the striking similarities with atherosclerosis. We first describe current epidemiological data showing the staggering increase of NAFLD numbers and its related clinical and economic costs. We then provide an overview of pathophysiological hepatic processes in NAFLD and highlight the systemic aspects of NAFLD that point toward metabolic crosstalk between organs as an important cause of metabolic disease. Finally, we end by highlighting the currently investigated therapeutic approaches for NAFLD, which also show strong similarities with a range of treatment options for atherosclerosis.
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28
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Hackl F, Kopylov A, Kaufman M. Cardiac Evaluation in Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00256-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Zhao J, Fang L, Song Y, Liang C. Letter: the association between chronic viral hepatitis and metabolic syndrome. Aliment Pharmacol Ther 2019; 49:232-233. [PMID: 30589966 DOI: 10.1111/apt.15037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Jian Zhao
- Department of Cardiology and Nursing, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Lingling Fang
- Department of Cardiology and Nursing, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yawen Song
- Department of Cardiology and Nursing, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chun Liang
- Department of Cardiology and Nursing, Changzheng Hospital, Second Military Medical University, Shanghai, China
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30
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Choudhary NS, Saigal S. Preventive Strategies for Nonalcoholic Fatty Liver Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:619-624. [PMID: 31695252 PMCID: PMC6823688 DOI: 10.1016/j.jceh.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Post-transplant nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) is common and can be recurrent or de novo. The available data suggest that progression of fibrosis is accelerated in these patients compared to NASH in general population. The long-term data suggest more risk of metabolic syndrome and associated metabolic comorbidities and cardiovascular disease in these patients. The current review focuses on prevalence and prevention/treatment of post-transplant NAFLD or NASH.
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Affiliation(s)
| | - Sanjiv Saigal
- Address for correspondence: Sanjiv Saigal, Director, Hepatology & Liver Transplant, Medanta Institute of Digestive & Hepatobiliary Sciences &Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, PIN 122001, India.
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31
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Choudhary NS, Duseja A. Screening of Cardiovascular Disease in Nonalcoholic Fatty Liver Disease: Whom and How? J Clin Exp Hepatol 2019; 9:506-514. [PMID: 31516267 PMCID: PMC6728527 DOI: 10.1016/j.jceh.2019.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/06/2019] [Indexed: 02/07/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide. Patients with NAFLD are at a higher risk of developing cardiovascular disease (CVD). In fact, CVD-related mortality is more common in patients with NAFLD in comparison to liver-related mortality. This association is related to the common metabolic risk factors such as obesity, dyslipidemia, diabetes, and hypertension shared by both NAFLD and CVD, and also there is independent association of NAFLD with CVD because of risk factors such as insulin resistance, systemic inflammation, and atherogenic dyslipidemia. While there is abundant literature on association of NAFLD with CVD, there is sparse literature regarding the screening for CVD in patients with NAFLD. In the current review article, we discuss as to which patients with NAFLD to screen and how to screen for CVD.
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Key Words
- BMI, Body Mass Index
- CAD, Coronary Artery Disease
- CI, Confidence Interval
- CVD, Cardiovascular Disease
- DM, Diabetes Mellitus
- DSE, Dobutamine Stress ECHO
- HDL, High-Density Lipoprotein
- ILTS, International Liver Transplantation Society
- LDL, Low-Density Lipoprotein
- NAFL, Nonalcoholic Fatty Liver
- NAFLD, Nonalcoholic Fatty Liver Disease
- NASH, Nonalcoholic Steatohepatitis
- OR, Odds Ratio
- atherosclerosis
- cirrhosis
- hs-CRP, High-Sensitivity C-Reactive Protein
- metabolic syndrome
- risk scores
- screening
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurgaon, Delhi (NCR), India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Ajay Duseja, DM, FAMS, FAASLD, FACG, FSGEI, Professor, Department of Hepatology, Sector 12, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India. Tel.: +91 172 2756336; fax: +91 0172 2744401.
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32
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Badawi A, Di Giuseppe G, Arora P. Cardiovascular disease risk in patients with hepatitis C infection: Results from two general population health surveys in Canada and the United States (2007-2017). PLoS One 2018; 13:e0208839. [PMID: 30540839 PMCID: PMC6291240 DOI: 10.1371/journal.pone.0208839] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/25/2018] [Indexed: 02/06/2023] Open
Abstract
The role of hepatitis C virus (HCV) infection in increasing the risk of cardiovascular disease (CVD) is controversial. The objective of the present study is to estimate the 10-year risk of CVD in HCV- positive subjects and describe their profile of cardiometabolic risk markers compared to HCV-negative subjects. We conducted a cross-sectional study to estimate 10-year CVD risk, calculated using the Framingham Risk Score (FRS), in participants from the Canadian Health Measures Survey (CHMS; 2007–2015, n = 10,115) and the US-National Health and Nutrition Examination Survey (NHANES; 2007–2016, n = 16,668). Subjects included in our analysis were aged 30 to 74 years with no prior history of CVD. FRS estimates, sociodemographic and cardiometabolic risk factors were compared between HCV- positive and -negative subjects in the two surveys. HCV-positive subjects had a distinct sociodemographic profile compared to their HCV-negative counterparts. Cardiometabolic risk factors, inflammatory markers and serum levels of micronutrients were comparable between the two survey populations, both in HCV-positive and -negative subjects. The average FRS in HCV-positive patients was in the range of “intermediate” 10-year CVD risk (i.e., 10–20%) and was significantly higher (P<0.01) than their HCV-negative counterparts who were within the “low” 10-year CVD risk range (i.e., ≤10%). Using a multivariable linear regression model adjusted for ethnicity, number of metabolic syndrome components and BMI, HCV infection was significantly associated with a 2.5–3.5% absolute risk increase of 10-year CVD (P<0.01). The results of the present study suggest a potential association between HCV infection and risk of subclinical and clinical CVD. The expansion of anti-HCV therapy may also contribute to reduced CVD risk and burden in patients with chronic HCV infection and should be explored further in other datasets and population modelling studies.
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Affiliation(s)
- Alaa Badawi
- Public Health Risk Sciences Division, Public Health Agency of Canada, Toronto, ON, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- * E-mail:
| | | | - Paul Arora
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Division of Enteric Diseases, National Microbiology Laboratory, Public Health Agency of Canada, Toronto, ON, Canada
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33
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Buckley AJ, Thomas EL, Lessan N, Trovato FM, Trovato GM, Taylor-Robinson SD. Non-alcoholic fatty liver disease: Relationship with cardiovascular risk markers and clinical endpoints. Diabetes Res Clin Pract 2018; 144:144-152. [PMID: 30170074 DOI: 10.1016/j.diabres.2018.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/08/2018] [Accepted: 08/14/2018] [Indexed: 02/08/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a common diagnosis and is increasing in prevalence worldwide. NAFLD is usually asymptomatic at presentation; progression of the disease is unpredictable, leading to the development of a variety of techniques for screening, diagnosis and risk stratification. Clinical methods in current use include serum biomarker panels, hepatic ultrasound, magnetic resonance imaging, and liver biopsy. NAFLD is strongly associated with the metabolic syndrome, and the most common cause of death for people with the condition is cardiovascular disease. Whether NAFLD is an independent cardiovascular risk factor needs exploration. NAFLD has been associated with surrogate markers of cardiovascular disease such as carotid intima-media thickness, the presence of carotid plaque, brachial artery vasodilatory responsiveness and CT coronary artery calcification score. There is no effective medical treatment for NAFLD and evidence is lacking regarding the efficacy of interventions in mitigating cardiovascular risk. Health care professionals managing patients with NAFLD should tackle the issue with early identification of risk factors and aggressive modification. Current management strategies therefore comprise lifestyle change, with close attention to known cardiovascular risk factors.
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Affiliation(s)
- Adam J Buckley
- Imperial College London, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine London, United Kingdom; Imperial College London Diabetes Centre, Research Department, Abu Dhabi, United Arab Emirates.
| | - E Louise Thomas
- University of Westminster, Department of Life Sciences, London, United Kingdom.
| | - Nader Lessan
- Imperial College London, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine London, United Kingdom; Imperial College London Diabetes Centre, Research Department, Abu Dhabi, United Arab Emirates.
| | - Francesca M Trovato
- University of Catania, Department of Clinical and Experimental Medicine, Catania, Italy
| | - Guglielmo M Trovato
- University of Catania, Department of Clinical and Experimental Medicine, Catania, Italy
| | - Simon D Taylor-Robinson
- Imperial College London, Division of Integrative Systems Medicine and Digestive Health, Department of Surgery and Cancer, London, United Kingdom.
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34
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Tsai MC, Yang TW, Wang CC, Wang YT, Sung WW, Tseng MH, Lin CC. Favorable clinical outcome of nonalcoholic liver cirrhosis patients with coronary artery disease: A population-based study. World J Gastroenterol 2018; 24:3547-3555. [PMID: 30131661 PMCID: PMC6102501 DOI: 10.3748/wjg.v24.i31.3547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/11/2018] [Accepted: 07/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To elucidate the prevalence and risk of mortality of nonalcoholic liver cirrhosis (LC) patients with coronary artery disease (CAD). METHODS The study cohort included newly diagnosed nonalcoholic LC patients age ≥ 40 years old without a diagnosis of CAD from 2006 until 2011 from a longitudinal health insurance database. The mean follow-up period for the study cohort was 1152 ± 633 d. The control cohort was matched by sex, age, residence, and index date. Hazard ratios (HRs) were calculated using the Cox proportional hazard model and the Kaplan-Meier method. RESULTS After exclusion, a total of 3409 newly diagnosed nonalcoholic cirrhotic patients were identified from one million samples from the health insurance database. We found that CAD (5.1% vs 17.4%) and hyperlipidemia (20.6% vs 24.1%) were less prevalent in nonalcoholic LC patients than in normal subjects (all P < 0.001), whereas other comorbidities exhibited an increased prevalence. Among the comorbidities, chronic kidney disease exhibited the highest risk for mortality (adjusted HR (AHR) = 1.76; 95%CI: 1.55-2.00, P < 0.001). Ascites or peritonitis exhibited the highest risk of mortality among nonalcoholic cirrhotic patients (AHR = 2.34; 95%CI: 2.06-2.65, P < 0.001). Finally, a total of 170 patients developed CAD after a diagnosis of nonalcoholic LC. The AHR of CAD in nonalcoholic LC patients was 0.56 (95%CI: 0.43-0.74, P < 0.001). The six-year survival rates for nonalcoholic LC patients with and without CAD were 52% and 50%, respectively (P = 0.012). CONCLUSION We conclude that CAD was less prevalent and associated with a reduced risk of mortality in nonalcoholic cirrhotic patients.
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Affiliation(s)
- Ming-Chang Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Tzu-Wei Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Institute and Department of Biological Science and Technology, National Chiao Tung University, Hsinchu 300, Taiwan
| | - Chi-Chih Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Yao-Tung Wang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Wen-Wei Sung
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ming-Hseng Tseng
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Medical Informatics, Chung Shan Medical University, Taichung 402, Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
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35
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Speliotes EK, Balakrishnan M, Friedman LS, Corey KE. Treatment of Dyslipidemia in Common Liver Diseases. Clin Gastroenterol Hepatol 2018; 16:1189-1196. [PMID: 29684459 PMCID: PMC6558967 DOI: 10.1016/j.cgh.2018.04.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/22/2018] [Accepted: 04/13/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Elizabeth K. Speliotes
- Department of Internal Medicine, Division of Gastroenterology and Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Maya Balakrishnan
- Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine, Houston, Texas
| | - Lawrence S. Friedman
- Departments of Medicine, Harvard Medical School, Tufts University School of Medicine, Newton-Wellesley Hospital, and Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen E. Corey
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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36
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Li B, Zhang C, Zhan YT. Nonalcoholic Fatty Liver Disease Cirrhosis: A Review of Its Epidemiology, Risk Factors, Clinical Presentation, Diagnosis, Management, and Prognosis. Can J Gastroenterol Hepatol 2018; 2018:2784537. [PMID: 30065915 PMCID: PMC6051295 DOI: 10.1155/2018/2784537] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/31/2018] [Accepted: 06/13/2018] [Indexed: 12/11/2022] Open
Abstract
Cirrhosis is the common end stage of a number of chronic liver conditions and a significant cause of morbidity and mortality. With the growing epidemic of obesity and metabolic syndrome, nonalcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease worldwide and will become one of the leading causes of cirrhosis. Increased awareness and understanding of NAFLD cirrhosis are essential. To date, there has been no published systematic review on NAFLD cirrhosis. Thus, this article reviews recent studies on the epidemiology, risk factors, clinical presentation, diagnosis, management, and prognosis of NAFLD cirrhosis.
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Affiliation(s)
- Bei Li
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Chuan Zhang
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Yu-Tao Zhan
- Department of Gastroenterology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
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37
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Danielsen KV, Wiese S, Hove J, Bendtsen F, Møller S. Pronounced Coronary Arteriosclerosis in Cirrhosis: Influence on Cardiac Function and Survival? Dig Dis Sci 2018. [PMID: 29516327 DOI: 10.1007/s10620-018-5006-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The relation between excessive alcohol consumption and coronary arteriosclerosis has remained controversial. The etiology of cirrhosis has been considered a substantial risk factor for development of arteriosclerotic lesions. The coronary artery calcium-score derived from coronary CT angiography is a robust marker of coronary arteriosclerosis. AIMS To study the burden of coronary arteriosclerosis in cirrhotic patients of various etiologies and association to cardiac dysfunction and survival. METHODS Fifty-seven patients with cirrhosis without cardiovascular disease underwent coronary CT angiography, tissue Doppler echocardiography, electrocardiogram and registration of clinical and biochemical characteristics. RESULTS In patients with cirrhosis the median coronary artery calcium-score was increased in comparison with age and race-adjusted healthy reference values (men: 328 vs. 9 HU and women: 136 vs. 0 HU; p < 0.001). Moreover, the coronary artery calcium-score in alcohol-related cirrhosis was significantly higher than in nonalcohol-related cirrhosis (362 vs. 46 HU, p < 0.001). Coronary artery calcium-score correlated with age (p = 0.002) but not with established cardiovascular risk factors including smoking, type 2 diabetes, hypertension, gender, or hypercholesterolemia. Coronary artery calcium-score was associated with diastolic dysfunction, lateral e´ (p = 0.025), but not with other markers of cardiac dysfunction. During a median follow-up of 25 months 12 patients (21%) died but coronary artery calcium-score was not associated with survival. CONCLUSIONS Coronary arteriosclerosis was particular extensive in patients with alcoholic cirrhosis. However, the current results suggest that coronary arteriosclerosis only have limited influence on cardiac function and survival. Surprisingly, no other established risk factors apart from age seemed to interfere with coronary arteriosclerosis in cirrhotic patients.
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Affiliation(s)
- Karen V Danielsen
- Centre for Functional and Diagnostic Imaging, Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark. .,Centre for Gastroenterology and Hepatology, Department of medicine, Hvidovre Hospital, Hvidovre, Denmark.
| | - Signe Wiese
- Centre for Functional and Diagnostic Imaging, Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark.,Centre for Gastroenterology and Hepatology, Department of medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Jens Hove
- Department of Cardiology, Hvidovre Hospital, Copenhagen, Denmark
| | - Flemming Bendtsen
- Centre for Gastroenterology and Hepatology, Department of medicine, Hvidovre Hospital, Hvidovre, Denmark
| | - Søren Møller
- Centre for Functional and Diagnostic Imaging, Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Hvidovre, Denmark
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38
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Lin SY, Lin CL, Lin CC, Wang IK, Hsu WH, Kao CH. Risk of acute coronary syndrome and peripheral arterial disease in chronic liver disease and cirrhosis: A nationwide population-based study. Atherosclerosis 2018; 270:154-159. [PMID: 29425961 DOI: 10.1016/j.atherosclerosis.2018.01.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND & AIMS Until now, no study has investigated the risks of acute coronary syndrome (ACS) and peripheral arterial disease (PAD) in cirrhosis. METHODS In this study, 57,214 patients diagnosed with cirrhosis between 2000 and 2010 were identified from the Taiwan National Health Insurance claims data. Each patient was randomly selected and frequency-matched with an individual without cirrhosis by age, sex, and index year. RESULTS The overall incidence rates of ACS and PAD were 2.81 and 2.97 per 1000 person-years, respectively, in the cirrhosis cohort. The cirrhosis cohort had a higher risk of ACS [adjusted subhazard ratio (aSHR) = 1.12, 95% confidence interval (CI) = 1.03-1.22] and PAD (aSHR = 1.11, 95% CI = 1.02-1.21). The risk of ACS was highest among members of the cirrhosis cohort with ascites (aSHR = 1.09, 95% CI = 1.11-1.19). CONCLUSIONS Patients with chronic liver disease and cirrhosis have higher risks of ACS and PAD than those without chronic liver disease and cirrhosis.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - I-Kuan Wang
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Division of Pulmonary and Critical Care Medicine, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taiwan; Department of Nuclear Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan.
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39
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VanWagner LB, Harinstein ME, Runo JR, Darling C, Serper M, Hall S, Kobashigawa JA, Hammel LL. Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: An evaluation of the evidence and consensus recommendations. Am J Transplant 2018; 18:30-42. [PMID: 28985025 PMCID: PMC5840800 DOI: 10.1111/ajt.14531] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/12/2017] [Accepted: 09/28/2017] [Indexed: 01/25/2023]
Abstract
Liver transplant (LT) candidates today are older, have greater medical severity of illness, and have more cardiovascular comorbidities than ever before. In addition, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Cirrhotic cardiomyopathy, a condition characterized by increased cardiac output and a reduced ventricular response to stress, is present in up to 30% of patients with cirrhosis, thus challenging perioperative management. Current noninvasive tests that assess for subclinical coronary and myocardial disease have low sensitivity, and altered hemodynamics during the LT surgery can unmask latent cardiovascular disease either intraoperatively or in the immediate postoperative period. Therefore, this review, assembled by a group of multidisciplinary experts in the field and endorsed by the American Society of Transplantation Liver and Intestine and Thoracic and Critical Care Communities of Practice, provides a critical assessment of the diagnosis of cardiac and pulmonary vascular disease and interventions aimed at managing these conditions in LT candidates. Key points and practice-based recommendations for the diagnosis and management of cardiac and pulmonary vascular disease in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.
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Affiliation(s)
- Lisa B. VanWagner
- Division of Gastroenterology and Hepatology, Department of Medicine and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Matthew E. Harinstein
- Heart and Vascular Institute, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - James R. Runo
- Division of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Christopher Darling
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Marina Serper
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Shelley Hall
- Division of Transplant Cardiology, Baylor University Medical Center, Dallas, TX USA
| | - Jon A. Kobashigawa
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Laura L. Hammel
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
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40
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Abstract
Liver transplantation (LT) is a unique surgical procedure that has major hemodynamic and cardiovascular implications. Recently, there has been significant interest focused on cardiovascular issues that affect LT patients in all phases of the perioperative period. The preoperative cardiac evaluation is a major step in the selection of LT candidates. LT candidates are aging in concordance with the general population; cardiovascular disease and their risk factors are highly associated with older age. Underlying cardiovascular disease has the potential to affect outcomes in LT patients and has a major impact on candidate selection. The prolonged hemodynamic and metabolic instability during LT may contribute to adverse outcomes, especially in patients with underlying cardiovascular disease. Cardiovascular events are not unusual during LT; transplant anesthesiologists must be prepared for these events. Advanced cardiovascular monitoring techniques and treatment modalities are now routinely used during LT. Postoperative cardiovascular complications are common in both the early and late posttransplant periods. The impact of cardiac complications on posttransplant mortality is well recognized. Emerging knowledge regarding cardiovascular disease in LT patients and its impact on posttransplant outcomes will have an important role in guiding the future perioperative management of LT patients.
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41
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Krill T, Brown G, Weideman RA, Cipher DJ, Spechler SJ, Brilakis E, Feagins LA. Patients with cirrhosis who have coronary artery disease treated with cardiac stents have high rates of gastrointestinal bleeding, but no increased mortality. Aliment Pharmacol Ther 2017; 46:183-192. [PMID: 28488370 DOI: 10.1111/apt.14121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 02/19/2017] [Accepted: 04/08/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with coronary artery disease (CAD) treated with stents require dual antiplatelet therapy (DAPT). For cirrhotics, who often have varices and coagulopathy, it is not clear if the risk of gastrointestinal bleeding (GIB) should preclude use of DAPT. AIM To compare GIB and mortality rates in cirrhotics with CAD treated medically or with stents. METHODS Using institutional databases, we identified patients with cirrhosis and CAD treated with stents or medical therapy between January 2000-September 2015. Primary outcomes were GIB and mortality. RESULTS We identified 148 cirrhotics with CAD; 68 received stents (cases), 80 were treated with medical therapy (controls). Cases and controls had similar demographics, comorbidities, MELD scores and clinical presentation; DAPT was used in 98.5% of cases vs 5% of controls. The incidence of GIB was significantly higher in cases than controls (22.1% vs 5% at 1 year, P=.003; 27.9% vs 5% at 2 years, P=.0002), whereas all-cause mortality was similar (20.6% vs 21.3%). No patient required surgery or angiography for GIB, and no known patients died due to GIB. Multivariate analysis revealed use of a proton pump inhibitor (PPI) was highly protective against GIB (OR=0.26, 95%CI=0.08-0.79). CONCLUSIONS CAD treatment with stents in our cirrhotics was associated with a significantly increased risk of GIB, but no adverse effects on survival. Although it remains unclear whether the cardiovascular benefits of stents outweigh the GIB risk, our findings suggest that DAPT should not be withheld from stented cirrhotics for fear of GIB. Moreover, the use of a PPI should be strongly considered.
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Affiliation(s)
- T Krill
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G Brown
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - R A Weideman
- Department of Pharmacy, VA North Texas Healthcare System, Dallas, TX, USA
| | - D J Cipher
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - S J Spechler
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - E Brilakis
- Division of Cardiology, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - L A Feagins
- Division of Digestive and Liver Disease, VA North Texas Healthcare System, Dallas, TX, USA.,Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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42
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Skaro AI, Gallon LG, Lyuksemburg V, Jay CL, Zhao L, Ladner DP, VanWagner LB, De Wolf AM, Flaherty JD, Levitsky J, Abecassis MM, Gheorghiade M. The impact of coronary artery disease on outcomes after liver transplantation. J Cardiovasc Med (Hagerstown) 2016; 17:875-885. [DOI: 10.2459/jcm.0000000000000207] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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43
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Ambrosino P, Lupoli R, Di Minno A, Tarantino L, Spadarella G, Tarantino P, Nasto A, Celentano A, Di Minno MND. The risk of coronary artery disease and cerebrovascular disease in patients with hepatitis C: A systematic review and meta-analysis. Int J Cardiol 2016; 221:746-54. [PMID: 27428315 DOI: 10.1016/j.ijcard.2016.06.337] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/30/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND/OBJECTIVES Some studies suggest that patients with hepatitis C virus (HCV) infection have an increased risk of coronary artery disease (CAD) and cerebrovascular disease. Unfortunately, available data on this association are widely variable. We have performed a systematic review and meta-analysis of literature to evaluate the risk of cardio-cerebrovascular disease (CCD) associated with HCV. METHODS Studies reporting on CCD risk associated with HCV were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. RESULTS Twenty-seven studies (34 data-sets) showed a significantly increased CCD risk in 297,613 HCV patients as compared with 557,814 uninfected controls (OR: 1.428; 95% CI: 1.214, 1.681). These results were confirmed when separately considering the risk of CAD (20 studies, OR: 1.382; 95% CI: 1.103, 1.732) and of cerebrovascular disease (13 studies, OR: 1.485; 95% CI: 1.079, 2.044). Similar results were confirmed when analyzing 21 studies reporting adjusted risk estimates (OR: 1.448; 95% CI: 1.218, 1.722) and when, after excluding studies defining CAD as positive angiographic or electrocardiographic evidence, we specifically included the 17 studies reporting on acute CCD-related events (OR: 1.357; 95% CI: 1.103, 1.670). Moreover, 4 studies evaluating CCD-related deaths showed a higher risk in HCV patients than controls (OR: 1.772; 95% CI: 1.448, 2.168; P<0.0001). Meta-regression models suggested a direct association between prevalence of cirrhosis and difference in CCD risk between HCV patients and controls. CONCLUSIONS Results of our large meta-analysis suggest that HCV-infected subjects experience an increased risk of CCD. This should be considered to plan specific cardiovascular prevention strategies in this clinical setting.
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Affiliation(s)
- Pasquale Ambrosino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Roberta Lupoli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Luciano Tarantino
- Department of Surgery, Interventional Hepatology, Andrea Tortora Hospital, Pagani, Italy
| | - Gaia Spadarella
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Paolo Tarantino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aurelio Nasto
- Department of Surgery, Unit of General Surgery and Oncology, Andrea Tortora Hospital, Pagani, Italy
| | - Aldo Celentano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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44
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Sehgal L, Srivastava P, Pandey CK, Jha A. Preoperative cardiovascular investigations in liver transplant candidate: An update. Indian J Anaesth 2016; 60:12-8. [PMID: 26962249 PMCID: PMC4782417 DOI: 10.4103/0019-5049.174870] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular complications are a major cause of morbidity and mortality in patients with end-stage liver disease (ESLD) undergoing liver transplantation. Identifying candidates at the highest risk of postoperative cardiovascular complications is the cornerstone for optimizing the outcome. Ischaemic heart disease contributes to major portion of cardiovascular complications and therefore warrants evaluation in the preoperative period. Patients of ESLD usually demonstrate increased cardiac output, compromised ventricular response to stress, low systemic vascular resistance and occasionally bradycardia. Despite various recommendations for preoperative evaluation of cardiovascular disease in liver transplant candidates, a considerable controversy on screening methodology persists. This review critically focuses on the rapidly expanding body of evidence for diagnosis and risk stratification of cardiovascular disorder in liver transplant candidates.
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Affiliation(s)
- Lalit Sehgal
- Liver Transplant Anaesthesia and Critical Care (SICU), Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Piyush Srivastava
- Liver Transplant Anaesthesia and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
| | - Chandra Kant Pandey
- Department of Anaesthesiology and Critical Care, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Amit Jha
- Liver Transplant Anaesthesia and Critical Care, Fortis Hospital, Noida, Uttar Pradesh, India
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45
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Wright AP, Adusumalli S, Corey KE. Statin therapy in patients with cirrhosis. Frontline Gastroenterol 2015; 6:255-261. [PMID: 28839820 PMCID: PMC5369584 DOI: 10.1136/flgastro-2014-100500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 07/24/2014] [Accepted: 07/25/2014] [Indexed: 02/04/2023] Open
Abstract
Cardiovascular disease is one of the leading causes of death among patients with cirrhosis and following liver transplantation. Although 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors ('statins') reduce the risk of cardiovascular events, fears about hepatotoxicity have historically led to underuse in patients with liver disease. In addition, the pharmacokinetics of statins can be significantly altered in cirrhosis, creating challenges with their use in liver disease. However, emerging data from randomised controlled trials and observational studies suggest that statin therapy appears to be safe and effective in patients with chronic liver disease and compensated cirrhosis. The cardiovascular risk benefits as well as the potential pleiotropic benefits of statins warrants strong consideration of use of statin therapy in patients with cirrhosis.
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Affiliation(s)
- Andrew P Wright
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Srinath Adusumalli
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen E Corey
- Harvard Medical School, Boston, Massachusetts, USA,Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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46
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Azzam H, Malnick S. Non-alcoholic fatty liver disease - the heart of the matter. World J Hepatol 2015; 7:1369-1376. [PMID: 26052382 PMCID: PMC4450200 DOI: 10.4254/wjh.v7.i10.1369] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 03/02/2015] [Accepted: 03/30/2015] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is one of the most common forms of chronic liver disease in the Western world. There is a close association with the metabolic syndrome and NAFLD is considered to be the hepatic manifestation of the metabolic syndrome. The components of the metabolic syndrome include hypertension, obesity and insulin resistance which are well established cardiovascular risk factors. The mortality rate of NAFLD patients from myocardial infarction is higher than that in the general United States population and there is also an increased risk of non-fatal cardiovascular events. This article reviews the cardiovascular complications associated with NAFLD. In order to provide comprehensive care of NAFLD patients, physicians need to be aware of, and search for, the cardiac morbidity associated with NAFLD.
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Affiliation(s)
- Haneen Azzam
- Haneen Azzam, Stephen Malnick, Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel
| | - Stephen Malnick
- Haneen Azzam, Stephen Malnick, Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel
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47
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Mozos I. Arrhythmia risk in liver cirrhosis. World J Hepatol 2015; 7:662-672. [PMID: 25866603 PMCID: PMC4388994 DOI: 10.4254/wjh.v7.i4.662] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 12/04/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
Abstract
Interactions between the functioning of the heart and the liver have been described, with heart diseases affecting the liver, liver diseases affecting the heart, and conditions that simultaneously affect both. The heart is one of the most adversely affected organs in patients with liver cirrhosis. For example, arrhythmias and electrocardiographic changes are observed in patients with liver cirrhosis. The risk for arrhythmia is influenced by factors such as cirrhotic cardiomyopathy, cardiac ion channel remodeling, electrolyte imbalances, impaired autonomic function, hepatorenal syndrome, metabolic abnormalities, advanced age, inflammatory syndrome, stressful events, impaired drug metabolism and comorbidities. Close monitoring of cirrhotic patients is needed for arrhythmias, particularly when QT interval-prolonging drugs are given, or if electrolyte imbalances or hepatorenal syndrome appear. Arrhythmia risk may persist after liver transplantation due to possible QT interval prolongation, persistence of the parasympathetic impairment, post-transplant reperfusion and chronic immunosuppression, as well as consideration of the fact that the transplant itself is a stressful event for the cardiovascular system. The aims of the present article were to provide a review of the most important data regarding the epidemiology, pathophysiology, and biomarkers of arrhythmia risk in patients with liver cirrhosis, to elucidate the association with long-term outcome, and to propose future research directions.
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48
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Parikh K, Appis A, Doukky R. Cardiac imaging for the assessment of patients being evaluated for kidney or liver transplantation. J Nucl Cardiol 2015; 22:282-96. [PMID: 25294437 DOI: 10.1007/s12350-014-9997-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 09/10/2014] [Indexed: 01/13/2023]
Abstract
Cardiac risk assessment prior to kidney and liver transplantation is controversial. Given the paucity of available organs, selecting appropriate recipients with favorable short- and long-term cardiovascular risk profile is crucial. Using noninvasive cardiac imaging tools to guide cardiovascular risk assessment and management can also be challenging and controversial. In this article, we address the burden of coronary artery disease among kidney and liver transplant candidates and review the literature pertaining to the diagnostic accuracy and the prognostic value of noninvasive cardiac imaging techniques in this population.
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Affiliation(s)
- Kalindi Parikh
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
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49
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Mechanisms of action for arsenic in cardiovascular toxicity and implications for risk assessment. Toxicology 2015; 331:78-99. [PMID: 25771173 DOI: 10.1016/j.tox.2015.02.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 02/09/2015] [Accepted: 02/27/2015] [Indexed: 11/20/2022]
Abstract
The possibility of an association between inorganic arsenic (iAs) exposure and cardiovascular outcomes has received increasing attention in the literature over the past decade. The United States Environmental Protection Agency (US EPA) is currently revising its Integrated Risk Assessment System (IRIS) review of iAs, and one of the non-cancer endpoints of interest is cardiovascular disease (CVD). Despite the increased interest in this area, substantial gaps remain in the available information, particularly regarding the mechanism of action (MOA) by which iAs could cause or exacerbate CVD. Few studies specifically address the plausibility of an association between iAs and CVD at the low exposure levels which are typical in the United States (i.e., below 100 μg As/L in drinking water). We have conducted a review and evaluation of the animal, mechanistic, and human data relevant to the potential MOAs of iAs and CVD. Specifically, we evaluated the most common proposed MOAs, which include disturbance of endothelial function and hepatic dysfunction. Our analysis of the available evidence indicates that there is not a well-established MOA for iAs in the development or progression of CVD. Few human studies of the potential MOAs have addressed plausibility at low doses and the applicability of extrapolation from animal studies to humans is questionable. However, the available evidence indicates that regardless of the specific MOA, the effects of iAs on physiological processes at the cellular level appear to operate via a threshold mechanism. This finding is consistent with the lack of association of CVD with iAs exposure in humans at levels below 100 μg/L, particularly when considering important exposure and risk modifiers such as nutrition and genetics. Based on this analysis, we conclude that there are no data supporting a linear dose-response relationship between iAs and CVD, indicating this relationship has a threshold.
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Association between liver fibrosis and coronary heart disease risk in patients with nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2015; 27:298-304. [PMID: 25629574 DOI: 10.1097/meg.0000000000000286] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is being increasingly recognized as the most common cause of chronic liver disease worldwide. It has been shown that NAFLD in adults is associated with increased risk of coronary heart disease (CHD). Because of the limitations of liver biopsy, noninvasive scoring indexes such as the NAFLD fibrosis score (NFS) were developed. The Framingham risk score (FRS) provides an estimate of CHD risk. In our study we aimed to investigate whether the severity of liver fibrosis estimated with the NFS is associated with a higher risk of CHD among individuals with ultrasonography-diagnosed NAFLD. STUDY A total of 155 patients and controls (81 patients with NAFLD and 74 controls) with ages ranging from 18 to 70 years were enrolled in this cross-sectional prospective study. Demographic, anthropometric, clinical, and laboratory data were obtained from each individual. The NAFLD patients were divided into subgroups on the basis of the severity of fatty liver. The FRS and NFS were adopted to predict the risk of CHD and the severity of hepatic fibrosis. RESULTS In our study, we found that the FRS was higher in NAFLD patients than in controls (P<0.05). According to the FRS category, NFSs were higher in the intermediate/high probability CHD risk group in NAFLD (P<0.05). In multiple models, only age, sex, cholesterol, and HDL were independently associated with intermediate/high CHD risk (P<0.05). We also found a positive correlation between the NFS and the FRS (r=0.373, P<0.001). The optimum NFS cutoff point for identifying intermediate/high CHD risk in NAFLD patients was -2.1284, with a sensitivity and specificity of 95.20 and 48.30%, respectively. The predictive performance of the NFS in the determination of intermediate/high CHD risk in NAFLD patients was found to be 72% based on the area under the curve value. CONCLUSION The FRS is associated with the NFS in NAFLD. The assessment of liver fibrosis may be useful for the risk stratification of CHD in the absence of liver biopsy in clinical practice.
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