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Ververeli CL, Dimitroglou Y, Soulaidopoulos S, Cholongitas E, Aggeli C, Tsioufis K, Tousoulis D. Cardiac Remodeling and Arrhythmic Burden in Pre-Transplant Cirrhotic Patients: Pathophysiological Mechanisms and Management Strategies. Biomedicines 2025; 13:812. [PMID: 40299454 PMCID: PMC12025098 DOI: 10.3390/biomedicines13040812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2025] [Revised: 03/22/2025] [Accepted: 03/25/2025] [Indexed: 04/30/2025] Open
Abstract
Background: Chronic liver disease (CLD) and cirrhosis contribute to approximately 2 million deaths annually, with primary causes including alcohol-related liver disease (ALD), metabolic dysfunction-associated steatotic liver disease (MASLD), and chronic hepatitis B and C infections. Among these, MASLD has emerged as a significant global health concern, closely linked to metabolic disorders and a leading cause of liver failure and transplantation. Objective: This review aims to highlight the interplay between cirrhosis and cardiac dysfunction, emphasizing the pathophysiology, diagnostic criteria, and management of cirrhotic cardiomyopathy (CCM). Methods: A comprehensive literature review was conducted to evaluate the hemodynamic and structural cardiac alterations in cirrhosis. Results: Cirrhosis leads to portal hypertension and systemic inflammation, contributing to CCM, which manifests as subclinical cardiac dysfunction, impaired contractility, and electrophysiological abnormalities. Structural changes, such as increased left ventricular mass, myocardial fibrosis, and ion channel dysfunction, further impair cardiac function. Vasodilation in the splanchnic circulation reduces peripheral resistance, triggering compensatory tachycardia, while the activation of the renin-angiotensin-aldosterone system (RAAS) promotes fluid retention and increases cardiac preload. Chronic inflammation and endotoxemia exacerbate myocardial dysfunction. The 2005 World Congress of Gastroenterology (WCG) and the 2019 Cirrhotic Cardiomyopathy Consortium (CCC) criteria provide updated diagnostic frameworks that incorporate global longitudinal strain (GLS) and tissue Doppler imaging (TDI). Prolonged QT intervals and arrhythmias are frequently observed. Managing heart failure in cirrhotic patients remains complex due to intolerance to afterload-reducing agents, and beta-blockers require careful use due to potential systemic hypotension. The interaction between CCM and major interventions, such as transjugular intrahepatic portosystemic shunt (TIPS) and orthotopic liver transplantation (OLT), highlights the critical need for thorough preoperative cardiac evaluation and vigilant postoperative monitoring. Conclusions: CCM is a frequently underdiagnosed yet significant complication of cirrhosis, impacting prognosis, particularly post-liver transplantation. Early identification using echocardiography and thorough evaluations of arrhythmia risk in cirrhotic patients are critical for optimizing management strategies. Future research should focus on targeted therapeutic approaches to mitigate the cardiac burden in cirrhotic patients and improve clinical outcomes.
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Affiliation(s)
- Charilila-Loukia Ververeli
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Yannis Dimitroglou
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Stergios Soulaidopoulos
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Evangelos Cholongitas
- 1st Department of Internal Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokrateio General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (C.-L.V.); (S.S.); (C.A.); (K.T.); (D.T.)
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Rankovic I, Babic I, Martinov Nestorov J, Bogdanovic J, Stojanovic M, Trifunovic J, Panic N, Bezmarevic M, Jevtovic J, Micic D, Dedovic V, Djuricic N, Pilipovic F, Curakova Ristovska E, Glisic T, Kostic S, Stojkovic N, Joksimovic N, Bascarevic M, Bozovic A, Elvin L, Onifade A, Siau K, Koriakovskaia E, Milivojevic V. Joint Group and Multi Institutional Position Opinion: Cirrhotic Cardiomyopathy-From Fundamentals to Applied Tactics. MEDICINA (KAUNAS, LITHUANIA) 2024; 61:46. [PMID: 39859028 PMCID: PMC11766788 DOI: 10.3390/medicina61010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Revised: 12/20/2024] [Accepted: 12/25/2024] [Indexed: 01/27/2025]
Abstract
Cirrhotic cardiomyopathy (CCM) is a diagnostic entity defined as cardiac dysfunction (diastolic and/or systolic) in patients with liver cirrhosis, in the absence of overt cardiac disorder. Pathogenically, CCM stems from a combination of systemic and local hepatic factors that, through hemodynamic and neurohormonal changes, affect the balance of cardiac function and lead to its remodeling. Vascular changes in cirrhosis, mostly driven by portal hypertension, splanchnic vasodilatation, and increased cardiac output alongside maladaptively upregulated feedback systems, lead to fluid accumulation, venostasis, and cardiac dysfunction. Autocrine and endocrine proinflammatory cytokines (TNF-alpha, IL-6), as well as systemic endotoxemia stemming from impaired intestinal permeability, contribute to myocardial remodeling and fibrosis, which further compromise the contractility and relaxation of the heart. Additionally, relative adrenal insufficiency is often present in cirrhosis, further potentiating cardiac dysfunction, ultimately leading to the development of CCM. Considering its subclinical course, CCM diagnosis remains challenging. It relies mostly on stress echocardiography or advanced imaging techniques such as speckle-tracking echocardiography. Currently, there is no specific treatment for CCM, as it vastly overlaps with the treatment of heart failure. Diuretics play a central role. The role of non-selective beta-blockers in treating portal hypertension is established; however, their role in CCM remains somewhat controversial as their effect on prognosis is unclear. However, our group still advocates them as essential tools in optimizing the neurohumoral pathologic axis that perpetuates CCM. Other targeted therapies with direct anti-inflammatory and antioxidative effects still lack sufficient evidence for wide approval. This is not only a review but also a comprehensive distillation of the insights from practicing clinical hepatologists and other specialties engaged in advanced approaches to treating liver disease and its sequelae.
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Affiliation(s)
- Ivan Rankovic
- Gastroenterology and Liver Unit, Royal Cornwall Hospitals NHS Trust, London TR1 3LJ, UK (A.O.); (K.S.)
- Medical School, University of Exeter, Exeter TR10 9FE, UK
| | - Ivana Babic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.B.); (N.J.); (A.B.)
| | - Jelena Martinov Nestorov
- Clinic for Gastroenterology and Hepatology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.M.N.); (J.J.); (T.G.); (V.M.)
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
| | - Jelena Bogdanovic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.B.); (N.J.); (A.B.)
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
| | - Maja Stojanovic
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia;
| | - Jovanka Trifunovic
- Faculty of Dentistry Pancevo, University of Business Academy in Novi Sad, 21 000 Novi Sad, Serbia;
| | - Nikola Panic
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
- Center for Digestive Endoscopy, University Clinic “Dr Dragisa Misovic”, 11 000 Belgrade, Serbia
| | - Mihailo Bezmarevic
- Clinic for General Surgery, Military Medical Academy, Military Medical Academy Medical Faculty, University of Defense, 11 000 Belgrade, Serbia;
| | - Jelena Jevtovic
- Clinic for Gastroenterology and Hepatology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.M.N.); (J.J.); (T.G.); (V.M.)
| | - Dusan Micic
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
- Clinic for Emergency Surgery, Emergency Centre, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia
| | - Vladimir Dedovic
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
- Clinic for Cardiology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia;
| | - Nemanja Djuricic
- Clinic for Cardiology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia;
| | - Filip Pilipovic
- Institute for Orthopedic Surgery “Banjica”, 11 000 Belgrade, Serbia;
| | | | - Tijana Glisic
- Clinic for Gastroenterology and Hepatology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.M.N.); (J.J.); (T.G.); (V.M.)
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
| | - Sanja Kostic
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia;
| | - Nemanja Stojkovic
- Department of Cardiology, University Clinic “Dr Dragisa Misovic”, 11 000 Belgrade, Serbia;
| | - Nata Joksimovic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.B.); (N.J.); (A.B.)
| | - Mileva Bascarevic
- Clinic for Allergy and Immunology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia;
| | - Aleksandra Bozovic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.B.); (N.J.); (A.B.)
| | - Lewis Elvin
- Gastroenterology and Liver Unit, Royal Cornwall Hospitals NHS Trust, London TR1 3LJ, UK (A.O.); (K.S.)
- Medical School, University of Exeter, Exeter TR10 9FE, UK
| | - Ajibola Onifade
- Gastroenterology and Liver Unit, Royal Cornwall Hospitals NHS Trust, London TR1 3LJ, UK (A.O.); (K.S.)
- Medical School, University of Exeter, Exeter TR10 9FE, UK
| | - Keith Siau
- Gastroenterology and Liver Unit, Royal Cornwall Hospitals NHS Trust, London TR1 3LJ, UK (A.O.); (K.S.)
- Medical School, University of Exeter, Exeter TR10 9FE, UK
| | - Elizaveta Koriakovskaia
- Department of Cardiology, Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia;
| | - Vladimir Milivojevic
- Clinic for Gastroenterology and Hepatology, University Clinical Centre of Serbia, 11 000 Belgrade, Serbia; (J.M.N.); (J.J.); (T.G.); (V.M.)
- Faculty of Medicine, University of Belgrade, 11 000 Belgrade, Serbia; (M.S.); (N.P.); (D.M.)
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Lupu D, Stănescu C, Nedelcu DL, Stoica GA, Botezat MM, Lupu AŞ. Electrophysiological parameters in patients with hepatic cirrhosis. ROMANIAN JOURNAL OF MORPHOLOGY AND EMBRYOLOGY = REVUE ROUMAINE DE MORPHOLOGIE ET EMBRYOLOGIE 2024; 65:687-692. [PMID: 39957031 PMCID: PMC11924892 DOI: 10.47162/rjme.65.4.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2024] [Accepted: 01/08/2025] [Indexed: 02/18/2025]
Abstract
Various electrophysiological abnormalities are noted in patients with cirrhosis, the most prevalent consisting of QT prolongation and autonomic dysfunction. This study aims to thoroughly evaluate these abnormalities in cirrhotic patients by utilizing various parameters and compare them with healthy individuals. We evaluated 60 patients with hepatic cirrhosis using a resting electrocardiogram (ECG), ECG during and after the Valsalva maneuver, 24-hour ambulatory ECG monitoring and a standardized ECG stress test. We then compared these results with a group of 50 patients who had no hepatic cirrhosis or other significant known pathologies and were not on any medical treatment. At rest, cirrhotic patients had a reduced Valsalva index compared to the control group, but no statistical differences were noted in comparing resting heart rate (HR) values. At Holter monitoring, although there was a trend toward increased corrected QT (QTc) intervals in cirrhotic patients, it did not reach statistical significance, indicating no difference between the two groups. Reduced standard deviation of normal-to-normal (NN) intervals (SDNN) values, statistically significant, were noted in cirrhotic patients compared to the control group, indicating autonomic dysfunction. At stress test, there was no statistically significant difference in the results obtained for maximum HR during exercise between the two groups. Also, the results showed that cirrhotic patients had statistically significantly higher HR values after exercise compared to the control group. In conclusion, cirrhotic patients presented an increased grade of autonomic dysfunction compared to healthy patients, but no differences were noted regarding QT interval abnormalities.
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Affiliation(s)
- Dragoş Lupu
- Department of Pediatric Surgery and Orthopedics, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Romania;
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Boudabbous M, Hammemi R, Gdoura H, Chtourou L, Moalla M, Mnif L, Amouri A, Abid L, Tahri N. Cirrhotic cardiomyopathy: a subject that's always topical. Future Sci OA 2024; 10:FSO954. [PMID: 38817353 PMCID: PMC11137786 DOI: 10.2144/fsoa-2023-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 12/13/2023] [Indexed: 06/01/2024] Open
Abstract
Cirrhosis is the final stage in the development of hepatic fibrosis in chronic liver disease. It is associated with major hemodynamic disturbances defining the hyperdynamic circulation and may be complicated by specific cardiac involvement or cirrhotic cardiomyopathy which is a silent clinical condition that typically remains asymptomatic until the late stages of liver disease. Recently, new criteria defining CC, based on modern concepts and knowledge of heart failure, have been proposed. Despite knowledge of the main mechanisms behind this entity, there is no specific treatment available for cirrhotic cardiomyopathy. The management approach for symptomatic cardiomyopathy in cirrhotic patients is similar to that for left ventricular failure in non-cirrhotic individuals.
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Affiliation(s)
- Mona Boudabbous
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Rania Hammemi
- Cardiology, Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Hela Gdoura
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Lassad Chtourou
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Manel Moalla
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Leila Mnif
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Ali Amouri
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Leila Abid
- Cardiology, Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
| | - Nabil Tahri
- Gastroenterology Department, Hédi Chaker Hospital, Sfax, Tunisia
- Medecin sfax university, Sfax university, Tunisia
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Han H, Chen J, Deng Z, Li T, Qi X, Deng W, Wu Z, Xiao C, Zheng W, Du Y. Propranolol can correct prolonged QT intervals in patients with cirrhosis. Front Pharmacol 2024; 15:1370261. [PMID: 38738176 PMCID: PMC11082742 DOI: 10.3389/fphar.2024.1370261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/27/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Prolonged QT intervals are extremely common in patients with cirrhosis and affect their treatment outcomes. Propranolol is often used to prevent gastroesophageal variceal hemorrhage in patients with cirrhosis; however, it is uncertain whether propranolol exerts a corrective effect on QT interval prolongation in patients with cirrhosis. AIM The study aimed to investigate the therapeutic effects of propranolol on patients with cirrhosis and prolonged QT intervals. METHODS A retrospective cohort study approach was adopted. Patients with cirrhosis complicated by moderate-to-severe gastroesophageal varices, who were hospitalized at the Affiliated Hospital of Guangdong Medical University between 1 December 2020 and 31 November 2022, were included in the study. The patients were divided into the propranolol and control groups based on whether they had received propranolol. Upon admission, the patients underwent tests on liver and kidney functions, electrolytes, and coagulation function, as well as abdominal ultrasonography and electrocardiography. In addition to conventional treatment, the patients were followed up after the use or non-use of propranolol for treatment and subsequently underwent reexamination of the aforementioned tests. RESULTS The propranolol group (26 patients) had an average baseline corrected QT (QTc) interval of 450.23 ± 37.18 ms, of which 14 patients (53.8%) exhibited QTc interval prolongation. Follow-up was continued for a median duration of 7.00 days after the administration of propranolol and conventional treatment. Electrocardiographic reexamination revealed a decrease in the QTc interval to 431.04 ± 34.64 ms (p = 0.014), and the number of patients with QTc interval prolongation decreased to five (19.2%; p < 0.001). After treatment with propranolol and multimodal therapy, QTc interval normalization occurred in nine patients with QTc interval prolongation, leading to a normalization rate of 64.3% (9/14). The control group (n = 58) had an average baseline QTc interval of 453.74 ± 30.03 ms, of which 33 patients (56.9%) exhibited QTc interval prolongation. After follow-up for a median duration of 7.50 days, the QTc interval was 451.79 ± 34.56 ms (p = 0.482), and the number of patients with QTc interval prolongation decreased to 30 (51.7%; p = 0.457). The QTc interval normalization rate of patients in the control group with QTc interval prolongation was merely 10.0% (3/33), which was significantly lower than that in the propranolol group (p < 0.001). CONCLUSION In patients with cirrhosis complicated by QT interval prolongation, the short-term use of propranolol aids in correction of a long QT interval and provides positive therapeutic value for cirrhotic cardiomyopathy.
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Affiliation(s)
- Huanqin Han
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Junlian Chen
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhirong Deng
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Tingting Li
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xiaoying Qi
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Wei Deng
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zunge Wu
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Chuli Xiao
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Weiqiang Zheng
- Department of Infectious Diseases and Hepatology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yujun Du
- Cardiovascular Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
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Almeida F, Sousa A. Cirrhotic cardiomyopathy: Pathogenesis, clinical features, diagnosis, treatment and prognosis. Rev Port Cardiol 2024; 43:203-212. [PMID: 38142819 DOI: 10.1016/j.repc.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/09/2023] [Accepted: 07/30/2023] [Indexed: 12/26/2023] Open
Abstract
Cardiac dysfunction among cirrhotic patients has long been recognized in the medical community. While it was originally believed to be a direct result of alcohol toxicity, in the last 30 years cirrhotic cardiomyopathy (CCM) has been described as a syndrome characterized by chronic cardiac dysfunction in cirrhotic patients in the absence of known cardiac disease, regardless of the etiology of cirrhosis. CCM occurs in about 60% of patients with cirrhosis and plays a critical role in disease progression and treatment outcomes. Due to its predominantly asymptomatic course, diagnosing CCM is challenging and requires a high index of suspicion and a multiparametric approach. Patients with CCM usually present with the following triad: impaired myocardial contractile response to exercise, inadequate ventricular relaxation, and electrophysiological abnormalities (notably prolonged QT interval). In recent years, research in this area has grown expeditiously and a new set of diagnostic criteria has been developed by the Cirrhotic Cardiomyopathy Consortium, to properly identify patients with CCM. Nevertheless, CCM is still largely unknown among clinicians, and a major part of its pathophysiology and treatment is yet to be understood. In the present work, we aim to compile and summarize the available data on the pathogenesis, clinical features, diagnosis, treatment, and prognosis of CCM.
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Affiliation(s)
| | - Alexandra Sousa
- Cardiology Department, Unidade Local de Saúde de Entre o Douro e Vouga, Santa Maria da Feira, Portugal; Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Centre for Health Technology and Services Research, Porto, Portugal; RISE - Health Research Network, Porto, Portugal
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Wu HHL, Rakisheva A, Ponnusamy A, Chinnadurai R. Hepatocardiorenal syndrome in liver cirrhosis: Recognition of a new entity? World J Gastroenterol 2024; 30:128-136. [PMID: 38312119 PMCID: PMC10835518 DOI: 10.3748/wjg.v30.i2.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/05/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Emerging evidence and perspectives have pointed towards the heart playing an important role in hepatorenal syndrome (HRS), outside of conventional understanding that liver cirrhosis is traditionally considered the sole origin of a cascade of pathophysiological mechanisms directly affecting the kidneys in this context. In the absence of established heart disease, cirrhotic cardiomyopathy may occur more frequently in those with liver cirrhosis and kidney disease. It is a specific form of cardiac dysfunction characterized by blunted contractile responsiveness to stress stimuli and altered diastolic relaxation with electrophysiological abnormalities. Despite the clinical description of these potential cardiac-related complications of the liver, the role of the heart has traditionally been an overlooked aspect of circulatory dysfunction in HRS. Yet from a physiological sense, temporality (prior onset) of cardiorenal interactions in HRS and positive effects stemming from portosystemic shunting demonstrated an important role of the heart in the development and progression of kidney dysfunction in cirrhotic patients. In this review, we discuss current concepts surrounding how the heart may influence the development and progression of HRS, and the role of systemic inflammation and endothelial dysfunction causing circulatory dysfunction within this setting. The temporality of heart and kidney dysfunction in HRS will be discussed. For a subgroup of patients who receive portosystemic shunting, the dynamics of cardiorenal interactions following treatment is reviewed. Continued research to determine the unknowns in this topic is anticipated, hopefully to further clarify the intricacies surrounding the liver-heart-kidney connection and improve strategies for management.
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Affiliation(s)
- Henry H L Wu
- Renal Research, Kolling Institute of Medical Research, Royal North Shore Hospital & The University of Sydney, St. Leonards (Sydney) 2065, New South Wales, Australia
| | - Amina Rakisheva
- Department of Cardiology, City Cardiological Center, Almaty 050000, Kazakhstan
| | - Arvind Ponnusamy
- Department of Renal Medicine, Royal Preston Hospital, Preston PR2 9HT, United Kingdom
| | - Rajkumar Chinnadurai
- Donal O’Donoghue Renal Research Centre & Department of Renal Medicine, Northern Care Alliance National Health Service Foundation Trust, Salford M6 8HD, United Kingdom
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Møller S, Wiese S, Barløse M, Hove JD. How non-alcoholic fatty liver disease and cirrhosis affect the heart. Hepatol Int 2023; 17:1333-1349. [PMID: 37770804 DOI: 10.1007/s12072-023-10590-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023]
Abstract
Liver diseases affect the heart and the vascular system. Cardiovascular complications appear to be a leading cause of death in patients with non-alcoholic fatty liver disease (NAFLD) and cirrhosis. The predominant histological changes in the liver range from steatosis to fibrosis to cirrhosis, which can each affect the cardiovascular system differently. Patients with cirrhotic cardiomyopathy (CCM) and NAFLD are at increased risk of impaired systolic and diastolic dysfunction and for suffering major cardiovascular events. However, the pathophysiological mechanisms behind these risks differ depending on the nature of the liver disease. Accurate assessment of symptoms by contemporary diagnostic modalities is essential for identifying patients at risk, for evaluating candidates for treatment, and prior to any invasive procedures. This review explores current perspectives within this field.
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Affiliation(s)
- Søren Møller
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark.
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Signe Wiese
- Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Mads Barløse
- Department Clinical Physiology and Nuclear Medicine 260, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Copenhagen University Hospital, Kettegaards alle 30, 2650, Hvidovre, Denmark
| | - Jens D Hove
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Hvidovre Hospital, Hvidovre, Denmark
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Jahangiri S, Abdiardekani A, Jamshidi S, Askarinejad A, Mosalamiaghili S, Bazrafshan M, Karimi M, Bazrafshan H, Bazrafshan drissi H. Electrocardiographic characteristics of cirrhotic patients and their association with Child-Pugh score. Clin Cardiol 2023; 46:967-972. [PMID: 37436825 PMCID: PMC10436787 DOI: 10.1002/clc.24089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Cardiac dysfunction is a serious complication of cirrhosis which is usually asymptomatic. We investigated the clinical and electrocardiographic (ECG)-related factors among patients with cirrhosis and our aim was to find any associations between ECG changes and the etiology of cirrhosis, as well as Child-Pugh score. HYPOTHESIS We hypothesized that some ECG-related factors, particularly prolonged QT interval, are more common in patients with cirrhosis. Also, these factors are associated with the severity of cirrhosis, measured by the Child-Pugh score. METHODS From April 2019 to December 2022, we reviewed admitted patients to Namazi and Abu-Ali Sina hospitals, Shiraz, Iran. Patients with confirmed diagnosis of cirrhosis and without concurrent disorders affecting the cardiovascular system were selected. Clinical and ECG-related data were then extracted for participants, and Child-Pugh score was calculated. RESULTS A total of 425 patients were included; the median age was 36 years, and 245 patients (57.6%) were men. Cryptogenic and primary sclerosing cholangitis were the most common etiologies. Prolonged QT followed by early transitional zone were the most common ECG changes (24.7% and 19.8%, respectively), which were significantly associated with the etiology of cirrhosis and Child-Pugh class. CONCLUSIONS Prolonged QT interval and presence of early transitional zone in patients with cirrhosis may indicate cardiac dysfunction, necessitating further evaluations.
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Affiliation(s)
- Soodeh Jahangiri
- Endocrine Research Center, Institute of Endocrinology and MetabolismIran University of Medical SciencesTehranIran
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Alireza Abdiardekani
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
- Department of Cardiology, Abu‐Ali Sina Charity HospitalShiraz University of Medical SciencesShirazIran
| | - Saideh Jamshidi
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Amir Askarinejad
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
| | | | - Mehdi Bazrafshan
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Mohamadreza Karimi
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Hanieh Bazrafshan
- Department of Neurology, Clinical Neurology Research CenterShiraz University of Medical SciencesShirazIran
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10
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Gîrleanu I, Trifan A, Huiban L, Muzica CM, Petrea OC, Sîngeap AM, Cojocariu C, Chiriac S, Cuciureanu T, Stafie R, Zenovia S, Stratina E, Rotaru A, Nastasa R, Sfarti C, Costache II, Stanciu C. Anticoagulation for Atrial Fibrillation in Patients with Decompensated Liver Cirrhosis: Bold and Brave? Diagnostics (Basel) 2023; 13:1160. [PMID: 36980468 PMCID: PMC10047341 DOI: 10.3390/diagnostics13061160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/07/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Atrial fibrillation is frequently diagnosed in patients with liver cirrhosis, especially in those with non-alcoholic steatohepatitis or alcoholic etiology. Anticoagulant treatment is recommended for thromboembolic protection in patients with atrial fibrillation. Considering the impaired coagulation balance in liver cirrhosis, predisposing patients to bleed or thrombotic events, the anticoagulant treatment is still a matter of debate. Although patients with liver cirrhosis were excluded from the pivotal studies that confirmed the efficacy and safety of the anticoagulant treatment in patients with atrial fibrillation, data from real-life cohorts demonstrated that the anticoagulant treatment in patients with liver cirrhosis could be safe. This review aimed to evaluate the recent data regarding the safety and efficacy of anticoagulant treatment in patients with decompensated liver cirrhosis. Direct oral anticoagulants are safer than warfarin in patients with compensated liver cirrhosis. In Child-Pugh class C liver cirrhosis, direct oral anticoagulants are contraindicated. New bleeding and ischemic risk scores should be developed especially for patients with liver cirrhosis, and biomarkers for bleeding complications should be implemented in clinical practice to personalize this treatment in a very difficult population represented by decompensated liver cirrhosis patients.
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Affiliation(s)
- Irina Gîrleanu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Cristina Maria Muzica
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Oana Cristina Petrea
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Ana-Maria Sîngeap
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Camelia Cojocariu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Stefan Chiriac
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Tudor Cuciureanu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Remus Stafie
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Sebastian Zenovia
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Ermina Stratina
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Adrian Rotaru
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Robert Nastasa
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Catalin Sfarti
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
| | - Irina Iuliana Costache
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Department, “Saint Spiridon” University Hospital, 700115 Iasi, Romania
| | - Carol Stanciu
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “Saint Spiridon” University Hospital, 700111 Iasi, Romania
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11
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Nakashima M, Nakamura K, Nishihara T, Ichikawa K, Nakayama R, Takaya Y, Toh N, Akagi S, Miyoshi T, Akagi T, Ito H. Association between Cardiovascular Disease and Liver Disease, from a Clinically Pragmatic Perspective as a Cardiologist. Nutrients 2023; 15:nu15030748. [PMID: 36771454 PMCID: PMC9919281 DOI: 10.3390/nu15030748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Cardiovascular diseases and liver diseases are closely related. Non-alcoholic fatty liver disease has the same risk factors as those for atherosclerotic cardiovascular disease and may also be a risk factor for atherosclerotic cardiovascular disease on its own. Heart failure causes liver fibrosis, and liver fibrosis results in worsened cardiac preload and congestion. Although some previous reports regard the association between cardiovascular diseases and liver disease, the management strategy for liver disease in patients with cardiovascular diseases is not still established. This review summarized the association between cardiovascular diseases and liver disease. In patients with non-alcoholic fatty liver disease, the degree of liver fibrosis progresses with worsening cardiovascular prognosis. In patients with heart failure, liver fibrosis could be a prognostic marker. Liver stiffness assessed with shear wave elastography, the fibrosis-4 index, and non-alcoholic fatty liver disease fibrosis score is associated with both liver fibrosis in patients with liver diseases and worse prognosis in patients with heart failure. With the current population ageing, the importance of management for cardiovascular diseases and liver disease has been increasing. However, whether management and interventions for liver disease improve the prognosis of cardiovascular diseases has not been fully understood. Future investigations are needed.
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12
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Yuan N, Oesterle A, Botting P, Chugh S, Albert C, Ebinger J, Ouyang D. High-Throughput Assessment of Real-World Medication Effects on QT Interval Prolongation: Observational Study. JMIR Cardio 2023; 7:e41055. [PMID: 36662566 PMCID: PMC9898836 DOI: 10.2196/41055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Drug-induced prolongation of the corrected QT interval (QTc) increases the risk for Torsades de Pointes (TdP) and sudden cardiac death. Medication effects on the QTc have been studied in controlled settings but may not be well evaluated in real-world settings where medication effects may be modulated by patient demographics and comorbidities as well as the usage of other concomitant medications. OBJECTIVE We demonstrate a new, high-throughput method leveraging electronic health records (EHRs) and the Surescripts pharmacy database to monitor real-world QTc-prolonging medication and potential interacting effects from demographics and comorbidities. METHODS We included all outpatient electrocardiograms (ECGs) from September 2008 to December 2019 at a large academic medical system, which were in sinus rhythm with a heart rate of 40-100 beats per minute, QRS duration of <120 milliseconds, and QTc of 300-700 milliseconds, determined using the Bazett formula. We used prescription information from the Surescripts pharmacy database and EHR medication lists to classify whether a patient was on a medication during an ECG. Negative control ECGs were obtained from patients not currently on the medication but who had been or would be on that medication within 1 year. We calculated the difference in mean QTc between ECGs of patients who are on and those who are off a medication and made comparisons to known medication TdP risks per the CredibleMeds.org database. Using linear regression analysis, we studied the interaction of patient-level demographics or comorbidities on medication-related QTc prolongation. RESULTS We analyzed the effects of 272 medications on 310,335 ECGs from 159,397 individuals. Medications associated with the greatest QTc prolongation were dofetilide (mean QTc difference 21.52, 95% CI 10.58-32.70 milliseconds), mexiletine (mean QTc difference 18.56, 95% CI 7.70-29.27 milliseconds), amiodarone (mean QTc difference 14.96, 95% CI 13.52-16.33 milliseconds), rifaximin (mean QTc difference 14.50, 95% CI 12.12-17.13 milliseconds), and sotalol (mean QTc difference 10.73, 95% CI 7.09-14.37 milliseconds). Several top QT prolonging medications such as rifaximin, lactulose, cinacalcet, and lenalidomide were not previously known but have plausible mechanistic explanations. Significant interactions were observed between demographics or comorbidities and QTc prolongation with many medications, such as coronary disease and amiodarone. CONCLUSIONS We demonstrate a new, high-throughput technique for monitoring real-world effects of QTc-prolonging medications from readily accessible clinical data. Using this approach, we confirmed known medications for QTc prolongation and identified potential new associations and demographic or comorbidity interactions that could supplement findings in curated databases. Our single-center results would benefit from additional verification in future multisite studies that incorporate larger numbers of patients and ECGs along with more precise medication adherence and comorbidity data.
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Affiliation(s)
- Neal Yuan
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Adam Oesterle
- Division of Cardiology, Department of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco, CA, United States
| | - Patrick Botting
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sumeet Chugh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Albert
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Joseph Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - David Ouyang
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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13
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Lee W, Vandenberk B, Raj SR, Lee SS. Prolonged QT Interval in Cirrhosis: Twisting Time? Gut Liver 2022; 16:849-860. [PMID: 35864808 PMCID: PMC9668500 DOI: 10.5009/gnl210537] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/07/2021] [Indexed: 11/04/2022] Open
Abstract
Approximately 30% to 70% of patients with cirrhosis have QT interval prolongation. In patients without cirrhosis, QT prolongation is associated with an increased risk of ventricular arrhythmias, such as torsade de pointes (TdP). In cirrhotic patients, there is likely a significant association between the corrected QT (QTc) interval and the severity of liver disease, and possibly with increased mortality. We present a stepwise overview of the pathophysiology and management of acquired long QT syndrome in cirrhosis. The QT interval is mainly determined by ventricular repolarization. To compare the QT interval in time it should be corrected for heart rate (QTc), preferably by the Fridericia method. A QTc interval >450 ms in males and >470 ms in females is considered prolonged. The pathophysiological mechanism remains incompletely understood, but may include metabolic, autonomic or hormonal imbalances, cirrhotic heart failure and/or genetic predisposition. Additional external risk factors for QTc prolongation include medication (IKr blockade and altered cytochrome P450 activity), bradycardia, electrolyte abnormalities, underlying cardiomyopathy and acute illness. In patients with cirrhosis, multiple hits and cardiac-hepatic interactions are often required to sufficiently erode the repolarization reserve before long QT syndrome and TdP can occur. While some risk factors are unavoidable, overall risk can be mitigated by electrocardiogram monitoring and avoiding drug interactions and electrolyte and acidbase disturbances. In cirrhotic patients with prolonged QTc interval, a joint effort by cardiologists and hepatologists may be useful and significantly improve the clinical course and outcome.
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Affiliation(s)
- William Lee
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Satish R. Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samuel S. Lee
- Liver Unit, Snyder Institute for Chronic Disease, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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14
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Nagraj S, Peppas S, Rubianes Guerrero MG, Kokkinidis DG, Contreras-Yametti FI, Murthy S, Jorde UP. Cardiac risk stratification of the liver transplant candidate: A comprehensive review. World J Transplant 2022; 12:142-156. [PMID: 36051452 PMCID: PMC9331410 DOI: 10.5500/wjt.v12.i7.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
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Affiliation(s)
- Sanjana Nagraj
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York City, NY 10461, United States
| | - Spyros Peppas
- Department of Gastroenterology, Athens Naval Hospital, Athens 115 21, Greece
| | | | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT 06510, United States
| | | | - Sandhya Murthy
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York City, NY 10467, United States
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15
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Kim SH, Lee JG, Ju HM, Choi S, Yang H, Koo BN. Propofol prevents further prolongation of QT interval during liver transplantation. Sci Rep 2022; 12:4636. [PMID: 35301381 PMCID: PMC8931121 DOI: 10.1038/s41598-022-08592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/28/2022] [Indexed: 11/21/2022] Open
Abstract
Here, we aimed to compare the effects of two anesthetic methods (desflurane inhalation anesthesia vs. propofol-based total intravenous anesthesia (TIVA)] on corrected QT interval (QTc) values during living donor liver transplantation. Altogether, 120 patients who underwent living donor liver transplantation were randomized to either the desflurane or TIVA group. The primary outcome was intraoperative QTc change. Other electrocardiogram, hemodynamic findings and postoperative outcomes were examined as secondary outcomes. QTc values were prolonged intraoperatively in both groups; however, the change was smaller in the TIVA group than in the desflurane group (PGroup × Time < 0.001). More patients had QTc values of > 500 ms in the desflurane group than in the TIVA group (63.3% vs. 28.3%, P < 0.001). In patients with preoperative QTc prolongation, QTc was further prolonged in the desflurane group, but not in the TIVA group (PGroup × Time < 0.001). Intraoperative norepinephrine and vasopressin use were higher in the desflurane group than in the TIVA group. Propofol-based TIVA may reduce QTc prolongation during living donor liver transplantation compared to that observed with desflurane inhalational anesthesia, particularly in patients with preoperative QTc prolongation. Additionally, patients managed with propofol-based TIVA required less vasopressor during the procedure as compared with those managed with desflurane inhalational anesthesia.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyang Mi Ju
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - SuYoun Choi
- Department of Anesthesiology and Pain Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyukjin Yang
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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16
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Development of the AI-Cirrhosis-ECG Score: An Electrocardiogram-Based Deep Learning Model in Cirrhosis. Am J Gastroenterol 2022; 117:424-432. [PMID: 35029163 PMCID: PMC9727935 DOI: 10.14309/ajg.0000000000001617] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/27/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cirrhosis is associated with cardiac dysfunction and distinct electrocardiogram (ECG) abnormalities. This study aimed to develop a proof-of-concept deep learning-based artificial intelligence (AI) model that could detect cirrhosis-related signals on ECG and generate an AI-Cirrhosis-ECG (ACE) score that would correlate with disease severity. METHODS A review of Mayo Clinic's electronic health records identified 5,212 patients with advanced cirrhosis ≥18 years who underwent liver transplantation at the 3 Mayo Clinic transplant centers between 1988 and 2019. The patients were matched by age and sex in a 1:4 ratio to controls without liver disease and then divided into training, validation, and test sets using a 70%-10%-20% split. The primary outcome was the performance of the model in distinguishing patients with cirrhosis from controls using their ECGs. In addition, the association between the ACE score and the severity of patients' liver disease was assessed. RESULTS The model's area under the curve in the test set was 0.908 with 84.9% sensitivity and 83.2% specificity, and this performance remained consistent after additional matching for medical comorbidities. Significant elevations in the ACE scores were seen with increasing model for end-stage liver disease-sodium score. Longitudinal trends in the ACE scores before and after liver transplantation mirrored the progression and resolution of liver disease. DISCUSSION The ACE score, a deep learning model, can accurately discriminate ECGs from patients with and without cirrhosis. This novel relationship between AI-enabled ECG analysis and cirrhosis holds promise as the basis for future low-cost tools and applications in the care of patients with liver disease.
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17
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Kaur H, Premkumar M. Diagnosis and Management of Cirrhotic Cardiomyopathy. J Clin Exp Hepatol 2022; 12:186-199. [PMID: 35068798 PMCID: PMC8766707 DOI: 10.1016/j.jceh.2021.08.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cirrhotic cardiomyopathy refers to the structural and functional changes in the heart leading to either impaired systolic, diastolic, electrocardiographic, and neurohormonal changes associated with cirrhosis and portal hypertension. Cirrhotic cardiomyopathy is present in 50% of patients with cirrhosis and is clinically seen as impaired contractility, diastolic dysfunction, hyperdynamic circulation, and electromechanical desynchrony such as QT prolongation. In this review, we will discuss the cardiac physiology principles underlying cirrhotic cardiomyopathy, imaging techniques such as cardiac magnetic resonance imaging and scintigraphy, cardiac biomarkers, and newer echocardiographic techniques such as tissue Doppler imaging and speckle tracking, and emerging treatments to improve outcomes. METHODS We reviewed available literature from MEDLINE for randomized controlled trials, cohort studies, cross-sectional studies, and real-world outcomes using the search terms "cirrhotic cardiomyopathy," "left ventricular diastolic dysfunction," "heart failure in cirrhosis," "liver transplantation," and "coronary artery disease". RESULTS Cirrhotic cardiomyopathy is associated with increased risk of complications such as hepatorenal syndrome, refractory ascites, impaired response to stressors including sepsis, bleeding or transplantation, poor health-related quality of life and increased morbidity and mortality. The evaluation of cirrhotic cardiomyopathy should also guide the feasibility of procedures such as transjugular intrahepatic portosystemic shunt, dose titration protocol of betablockers, and liver transplantation. The use of targeted heart rate reduction is of interest to improve cardiac filling and improve the cardiac output using repurposed heart failure drugs such as ivabradine. Liver transplantation may also reverse the cirrhotic cardiomyopathy; however, careful cardiac evaluation is necessary to rule out coronary artery disease and improve cardiac outcomes in the perioperative period. CONCLUSION More data are needed on the new diagnostic criteria, molecular and biochemical changes, and repurposed drugs in cirrhotic cardiomyopathy. The use of advanced imaging techniques should be incorporated in clinical practice.
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Key Words
- 2-AG, 2-arachidonylglycerol
- 2D, two-dimensional
- AEA, Anandamide
- ANP, Atrial Natriuretic Peptide
- ASE, the American Society of Echocardiography
- AUC, area under the curve
- BA, bile acid
- BNP, Brain natriuretic peptide
- CAD, coronary artery disease
- CB-1, cannabinoid −1
- CCM, Cirrhotic Cardiomyopathy
- CMR, cardiovascular magnetic resonance imaging
- CO, cardiac output
- CT, computed tomography
- CTP, Child–Turcotte–Pugh
- CVP, central venous pressure
- DT, deceleration Time
- ECG, electrocardiogram
- ECV, extracellular volume
- EF, Ejection fraction
- EMD, electromechanical desynchrony
- ESLD, end-stage liver disease
- FXR, Farnesoid X receptor
- GI, gastrointestinal
- GLS, Global Longitudinal strain
- HCN, Hyperpolarization-activated cyclic nucleotide–gated
- HE, hepatic encephalopathy
- HF, heart failure
- HO, Heme oxygenase
- HPS, hepatopulmonary syndrome
- HR, heart rate
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- HfmrEF, heart failure with mid-range ejection fraction
- HfrEF, heart failure with reduced ejection fraction
- IVC, Inferior Vena Cava
- IVCD, IVC Diameter
- IVS, intravascular volume status
- L-NAME, NG-nitro-L-arginine methyl ester
- LA, left atrium
- LAVI, LA volume index
- LGE, late gadolinium enhancement
- LT, liver transplant
- LV, left ventricle
- LVDD, left ventricular diastolic dysfunction
- LVEDP, left ventricular end-diastolic pressure
- LVEDV, LV end diastolic volume
- LVEF, left ventricular ejection fraction
- LVESV, LV end systolic volume
- LVOT, left ventricular outflow tract
- MAP, mean arterial pressure
- MELD, Model for End-Stage Liver Disease
- MR, mitral regurgitation
- MRI, Magnetic resonance imaging
- MV, mitral valve
- NAFLD, Nonalcoholic fatty liver disease
- NO, nitric oxide
- NOS, Nitric oxide synthases
- NTProBNP, N-terminal proBNP
- PAP, pulmonary artery pressure
- PCWP, pulmonary capillary wedged pressure
- PHT, portal hypertension
- PWD, Pulsed-wave Doppler
- RV, right ventricle
- RVOT, right ventricular outflow tract
- SA, sinoatrial
- SD, standard deviation
- SV, stroke volume
- SVR, Systemic vascular resistance
- TDI, tissue Doppler imaging
- TIPS, transjugular intrahepatic portosystemic shunt
- TR, Tricuspid valve
- TRPV1, transient receptor potential cation channel subfamily V member 1
- TTE, transthoracic echocardiography
- USG, ultrasonography
- VTI, velocity time integral
- beta blocker
- cirrhotic cardiomyopathy
- hemodynamics in cirrhosis
- left ventricular diastolic dysfunction
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Affiliation(s)
| | - Madhumita Premkumar
- Address for correspondence: Dr. Madhumita Premkumar, M.D., D.M., Department of Hepatology, Postgraduate Institute of Medical Education and Research, 60012, Chandigarh, India. Tel.: ++91-9540951061 (mobile)
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18
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Bhangui P, Bhangui P, Aneja M, Sharma N, Gupta N, Soin A, Vohra V. Living Donor Liver Transplantation in a Cohort of Recipients With Left Ventricular Systolic Dysfunction. J Clin Exp Hepatol 2022; 12:1040-1047. [PMID: 35814511 PMCID: PMC9257861 DOI: 10.1016/j.jceh.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Data on feasibility, management, and outcomes of liver transplantation (LT) in patients with pre-existing left ventricular systolic dysfunction (LVSD), severe coronary artery disease (CAD) or cirrhotic cardiomyopathy (CCM) is scarce. METHODS We reviewed outcomes of living donor liver transplantation (LDLT) in recipients with LVSD (ejection fraction [EF] < 50%) from our series of 1946 LDLT's performed between July 2010 and July 2018. RESULTS LVSD was detected in 12 male patients with a mean age, BMI and MELD of 52 ± 9 years, 25 ± 5 kg/m2, and 19 ± 4 respectively. Out of these, 6 patients had CAD (2 with previous coronary artery bypass graft, 1 following recent percutaneous transluminal coronary angioplasty, 2 post myocardial infarction, 1 noncritical CAD), and 6 had CCM. The EF ranged from 25% to 45%. Ethanol was the predominant underlying etiology for cirrhosis (50%). During LDLT, 2 patients developed ventricular ectopic rhythm and were managed successfully with intravenous lidocaine. Stress cardiomyopathy manifested in 3 patients post operatively with decreased EF, of which 2 improved, while 1 needed IABP support and succumbed to multiorgan failure on 8th postoperative day (POD). Another patient died on POD30 due to septic shock. Both these patients had higher MELD scores (actual MELD), extremes of BMI (17.3and 35.8 kg/m2) and were diabetic. There were no long-term cardiac deaths. The 1-year, and 5-year survival were 75%, and 66%, respectively. CONCLUSION Among potential LT recipients with LVSD, those with stable CAD and good performance status, and well optimized CCM patients may be considered for LDLT after careful risk stratification in experienced centers.
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Key Words
- CABG, Coronary artery bypass graft
- CAC, coronary artery calcium score
- CAD, coronary artery disease
- CCM, cirrhotic cardiomyopathy
- CLD, chronic liver disease
- CTP, Child Turcotte Pugh
- DDLT, Deceased donor liver transplantation
- DSE, dobutamine stress echo
- ECG, electrocardiogram
- EF, ejection fraction
- ESLD, end stage liver disease
- GRWR, Graft to recipient weight ratio
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- IABP, intra-aortic balloon pump
- ICU, intensive care unit
- LDLT outcomes
- LDLT, Living donor liver transplantation
- LT, Liver transplantation
- LVSD, left ventricular systolic dysfunction
- MELD, Model for End Stage Liver Disease
- METS score, metabolic equivalents score
- NAFLD, nonalcoholic fatty liver disease
- OS, Overall survival
- PAC, pulmonary artery catheter
- PHT, portal hypertension
- PTCA, percutaneous transluminal coronary angioplasty
- TEE, transesophageal echocardiography
- cardiac complications
- cardiac evaluation
- cirrhotic cardiomyopathy
- coronary artery disease
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Affiliation(s)
- Pooja Bhangui
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
- Address for correspondence: Pooja Bhangui, Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurugram, Delhi, 122001, NCR, India.
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Manish Aneja
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nishant Sharma
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - Nikunj Gupta
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
| | - A.S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Vijay Vohra
- Department of Liver Transplant and GI Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
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19
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Luo Y, Wu B, Wu Y, Peng L, Li Z, Zhu J, Su Z, Liu J, Li S, Chong Y. Atrial fibrillation increases inpatient and 4-year all-cause mortality in critically ill patients with liver cirrhosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1239. [PMID: 34532376 PMCID: PMC8421951 DOI: 10.21037/atm-21-3111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/22/2021] [Indexed: 12/18/2022]
Abstract
Background The association between atrial fibrillation (AF) and cirrhosis is unclear. Therefore, the aim of the present study was to determine the association between AF and short-term and 4-year mortality in critically ill patients with cirrhosis using a large database. Methods The Medical Information Mart for Intensive Care III (MIMIC III) database was used to identify patients with cirrhosis hospitalized in an intensive care unit from 2001 to 2012. Demographic and clinical data were extracted from the database. Clinical data and demographic information were collected for each patient in our study. Kaplan-Meier analysis and multivariate Cox regression models were performed to examine the relation between atrial fibrillation and in-hospital and 4-year all-cause mortality. Results A total of 1,481 patients (mean age: 58 years, 68% male) with liver cirrhosis were included in the analysis, and the prevalence of AF was 14.18%. The inpatient all-cause mortality rate was 26.6%, and patients who died in hospital had a significantly higher rate of AF (21.57% vs. 11.50%, P<0.001). Multivariate Cox regression analysis indicated that AF was significantly associated with inpatient all-cause mortality [hazard ratio (HR): 1.52, 95% confidence interval (CI): 1.19–1.95, P<0.001], and 4-year all-cause mortality (HR: 1.55, 95% CI: 1.12–2.13, P=0.008). Kaplan-Meier survival analysis showed that patients with AF had a significantly higher inpatient and 4-year all-cause mortality. Conclusions Critically ill patients with liver cirrhosis have a high rate of AF, and the presence of AF is an independent risk factor for inpatient and 4-year all-cause mortality.
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Affiliation(s)
- Yanting Luo
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bingyuan Wu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuankai Wu
- Department of Infectious Diseases, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Long Peng
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zexiong Li
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jieming Zhu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongzhen Su
- Department of Ultrasound, Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Jinlai Liu
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Suhua Li
- Department of Cardiovascular Medicine, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yutian Chong
- Department of Infectious Diseases, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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20
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Kasper P, Steffen HM, Michels G. [Cirrhotic cardiomyopathy]. Dtsch Med Wochenschr 2021; 146:1070-1076. [PMID: 34416775 DOI: 10.1055/a-1321-9523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A cirrhotic cardiomyopathy (CCM) can be observed in patients with end-stage liver disease and is characterized by a systolic and/or diastolic dysfunction in the absence of pre-existing heart diseases. While the cardiac dysfunction is often masked at rest, it typically manifests itself during cardiovascular challenges such as hypovolemia, physical stress, or sepsis. The diagnosis of CCM is challenging and predominantly based on echocardiographic measurements to identify subclinical cardiac dysfunction. Additional diagnostic criteria include electrophysiological abnormalities such as QT-interval prolongation, an abnormal chronotropic or inotropic response to stress, elevated cardiac biomarkers such as natriuretic peptides, and structural cardiac abnormalities like left atrium enlargement. There is no specific therapy for CCM. Supportive measures and regular cardiac evaluation of high-risk patients and transplant candidates are important to reduce the risks associated with invasive procedures and treatments.
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21
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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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22
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Bhatti S, Rashed H, Abell T. Autonomic Nervous System Profiling In Response to Liver Transplantation: Prognostic Evaluation and Preliminary Study. Transplant Proc 2021; 53:1711-1718. [PMID: 33994186 DOI: 10.1016/j.transproceed.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 03/12/2021] [Accepted: 04/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Liver cirrhosis leads to autonomic dysfunction (AD). We present a pilot study and review of published literature to investigate the long-term changes in the Autonomic Nervous System (ANS) of patients who underwent liver transplant. We propose Autonomic Function Tests (AFT) can be used as a predictor of liver transplant outcome. METHODS Twenty-eight patients (19 men and 9 women; mean age 45 years) with cirrhosis due to different etiologies underwent a noninvasive ANS evaluation test, pre- and post-liver transplant at 3 to 6 months, 8 to 12 months, and 14 to 24 months. Data were compared with 45 age-matched controls (14 men and 31 women). We investigated changes in the following 3 adrenergic measures: percentage of cutaneous vasoconstriction in the hand and foot in response to cold stress test and cutaneous blood flow adjustment ratio; and 3 cardiovagal measures: change in heart rate in relation to deep respiration, forced respiration represented as Valsalva Ratio, and head-up tilting (30/15 ratio). RESULTS A total of 23 of 28 patients (82%) had impairment in AFT before transplant, 16 of 28 (57%) in the sympathetic adrenergic measures, and 15 of 28 (54%) in the parasympathetic cardiovagal measures. There was a gradual improvement in ANS function posttransplant, with a significant improvement in the cardiovagal measure of Valsalva Ratio (P < .05 from baseline). These data suggest some temporary decline in ANS functions within the first 6 months posttransplant. CONCLUSIONS To optimize outcomes in liver transplant patients with autonomic dysfunction, autonomic testing perhaps combined with frailty testing can be used as objective measures of mortality in the pre-liver transplant stage.
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Affiliation(s)
- Sundus Bhatti
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Hani Rashed
- University of Louisville, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Louisville, Kentucky
| | - Thomas Abell
- University of Louisville, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Louisville, Kentucky.
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23
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Razpotnik M, Bota S, Wimmer P, Hackl M, Lesnik G, Alber H, Peck-Radosavljevic M. The prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. Liver Int 2021; 41:1058-1069. [PMID: 33342074 DOI: 10.1111/liv.14769] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 12/01/2020] [Accepted: 12/11/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Recently published criteria by 2019 Cirrhotic Cardiomyopathy Consortium set a lower threshold for reduced ejection fraction to diagnose systolic dysfunction in cirrhotic patients, and stress testing was replaced by echocardiography strain imaging. The criteria to diagnose diastolic dysfunction are in general concordant with the 2016 ASE/EACVI guidelines and differ considerably from the 2005 Montreal recommendations. We aimed to assess the prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria. METHODS Cirrhotic patients without another structural heart disease, arterial hypertension, portal vein thrombosis, HCC outside Milan criteria and presence of TIPS were enrolled. Speckle-tracking echocardiography was performed by EACVI certified investigators. RESULTS A total of 122 patients with cirrhosis fulfilled the inclusion criteria. Overall prevalence of cirrhotic cardiomyopathy was similar for 2005 Montreal and 2019 CCC: 67.2% vs 55.7% (P = .09); and significantly higher compared to 2009 ASE/EACVI criteria: 67.2% vs 35.2% (P < .0001) and 55.7% vs 35.2% (P = .002) respectively. Significantly more patients had diastolic dysfunction according to the 2005 Montreal compared to the 2009 ASE/EACVI and 2019 CCC criteria: 64.8% vs 32.8% (P < .0001) and 64.8% vs 7.4% (P < .0001). Systolic dysfunction was more frequently diagnosed according to 2019 CCC criteria compared to 2005 Montreal (53.3% vs 16.4%,P < .0001) or ASE/EACVI criteria (53.3% vs 4.9%,P < .0001). CONCLUSION Cirrhotic cardiomyopathy was present in around 60% of cirrhotic patients when applying the hepatological criteria. A considerably higher prevalence of systolic dysfunction according to the 2019 CCC criteria was observed. Long-term follow-up studies are needed to establish the validity of these criteria to predict clinically relevant outcomes.
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Affiliation(s)
- Marcel Razpotnik
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Simona Bota
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Philipp Wimmer
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Michael Hackl
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Gerald Lesnik
- Institut for diagnostic and interventional Radiology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Hannes Alber
- Department of Internal Medicine and Cardiology (IMuK), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
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24
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Li S, Hao X, Liu S, Gong Y, Niu W, Tang Y. Prolonged QTc interval predicts long-term mortality in cirrhosis: a propensity score matching analysis. Scand J Gastroenterol 2021; 56:570-577. [PMID: 33792461 DOI: 10.1080/00365521.2021.1901307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Prolonged corrected QT (QTc) interval is a hallmark of cirrhotic cardiomyopathy (CCM) and has been ascertained to predict mortality in cirrhosis. However, some critical issues remain to be addressed including unanimous cut-off, calculation approach and applicable population. METHODS A total of 274 patients with cirrhosis were included. The prolonged QTc interval over 440 ms according to adjusted Fridericia's formula was used to stratify enrolled subjects. Independent predictors of 3-year mortality were identified with Cox regression model. The Kaplan-Meier method was implemented to obtain survival curves. To reduce impact of selection bias and possible confounders, a propensity score matching (PSM) analysis was used. RESULTS QTc > 440 ms was an independent risk factor in the entire cohort and PSM subset (HR 2.532, 95% CI 1.431-4.480, p=.001; HR 2.802, 95% CI 1.171-6.701, p=.021, respectively). Subgroup analysis showed that QTc > 440 ms was an independent predictor in cirrhotics with age ≤60 years (HR = 1.02, p=.035) and in the presence of ascites (HR = 1.01, p=.008). CONCLUSIONS The prolonged QTc interval might help to identify patients with high-risk of all-cause mortality.
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Affiliation(s)
- Shuhong Li
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
| | - Xuwen Hao
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
| | - Simiao Liu
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
| | - Yanxia Gong
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
| | - Wei Niu
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
| | - Yanping Tang
- Department of Gastroenterology, Tianjin Nankai Hospital, Tianjin, China
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25
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Kim KS, Kwon HM, Jung KW, Sang BH, Moon YJ, Kim B, Jun IG, Song JG, Hwang GS. Markedly prolonged QTc interval in end-stage liver disease and risk of 30-day cardiovascular event after liver transplant. J Gastroenterol Hepatol 2021; 36:758-766. [PMID: 32804412 DOI: 10.1111/jgh.15179] [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: 04/16/2020] [Revised: 06/22/2020] [Accepted: 07/09/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The proportional increase of corrected QT interval (QTc) along end-stage liver disease (ESLD) severity may lead to inconsistent outcome reporting if based on conventional threshold of prolonged QTc. We investigated the comprehensive QTc distribution among ESLD patients and assessed the association between QTc > 500 ms, a criterion for diagnosing severe long-QT syndrome, and the 30-day major adverse cardiovascular event (MACE) after liver transplantation (LT) and identified the risk factors for developing QTc > 500 ms. METHODS Data were collected prospectively from the Asan LT Registry between 2011 and 2018, and outcomes were retrospectively reviewed. Multivariable analysis and propensity score-weighted adjusted odds ratios (ORs) were calculated. Thirty-day MACEs were defined as the composite of cardiovascular mortality, arrhythmias, myocardial infarction, pulmonary thromboembolism, and/or stroke. RESULTS Of 2579 patients, 194 (7.5%) had QTc > 500 ms (QTc500_Group), and 1105 (42.8%) had prolonged QTc (QTcP_Group), defined as QTc > 470 ms for women and >450 ms for men. The 30-day MACE occurred in 336 (13%) patients. QTc500_Group showed higher 30-day MACE than did those without (20.1% vs 12.5%, P = 0.003), with corresponding adjusted OR of 1.24 (95% CI: 1.06-1.46, P = 0.007). However, QTcP_Group showed comparable 30-day MACE (13.3% vs 12.8% without prolonged QTc, P = 0.764). Significant risk factors for QTc > 500 ms development were advanced liver disease, female sex, hypokalemia, hypocalcemia, high left ventricular end-diastolic volume, and tachycardia. CONCLUSION Our results revealed that, among ESLD patients, a novel threshold of QTc > 500 ms was associated with post-LT 30-day MACE but not with conventional threshold, indicating that a longer QTc threshold should be considered for this unique patient population.
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Affiliation(s)
- Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo-Hyun Sang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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26
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Koshy AN, Ko J, Farouque O, Cooray SD, Han HC, Cailes B, Gow PJ, Weinberg L, Testro A, Lim HS, Teh AW. Effect of QT interval prolongation on cardiac arrest following liver transplantation and derivation of a risk index. Am J Transplant 2021; 21:593-603. [PMID: 32530547 DOI: 10.1111/ajt.16145] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/01/2020] [Accepted: 06/06/2020] [Indexed: 01/25/2023]
Abstract
Liver transplantation (LT) has a 4-fold higher risk of periprocedural cardiac arrest and ventricular arrhythmias (CA/VAs) compared with other noncardiac surgeries. Prolongation of the corrected QT interval (QTc) is common in patients with liver cirrhosis. Whether it is associated with an increased risk of CA/VAs following LT is unclear. Rates of 30-day CA/VAs post-LT were assessed in consecutive adults undergoing LT between 2010 and 2017. Pretransplant QTc was measured by a cardiologist blinded to clinical outcomes. Among 408 patients included, CA/VAs occurred in 26 patients (6.4%). QTc was significantly longer in CA/VA patients (475 ± 34 vs 450 ± 34 ms, P < .001). Optimal QTc cut-off for prediction of CA/VAs was ≥480 ms. After adjustment, QTc ≥480 ms remained the strongest predictor for the occurrence of CA/VAs (odds ratio [OR] 5.2, 95% confidence interval [CI] 2.2-12.6). A point-based cardiac arrest risk index (CARI) was derived with the bootstrap method for yielding optimism-corrected coefficients (2 points: QTc ≥480, 1 point: Model for End-Stage Liver Disease [MELD] ≥30, 1 point: age ≥65, and 1 point: male). CARI score ≥3 demonstrated moderate discrimination (c-statistic 0.79, optimism-corrected c-statistic 0.77) with appropriate calibration. QTc ≥480 ms was associated with a 5-fold increase in the risk of CA/VAs. The CARI score may identify patients at higher risk of these events. Whether heightened perioperative cardiac surveillance, avoidance of QT prolonging medications, or beta blockers could mitigate the risk of CA/VAs in this population merits further study.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Jefferson Ko
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Shamil D Cooray
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Paul J Gow
- The University of Melbourne, Parkville, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia.,Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Adam Testro
- The University of Melbourne, Parkville, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Parkville, Victoria, Australia.,Cardiology Department, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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27
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Ou M, Tian Y, Zhuang G, Peng Y. QTc interval prolongation in liver cirrhosis with upper gastrointestinal bleeding. Med Clin (Barc) 2020; 156:68-75. [PMID: 33309043 DOI: 10.1016/j.medcli.2020.06.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 10/22/2022]
Abstract
QTc interval prolongation is common in patients with liver cirrhosis. Cirrhotic patients suffering from complications could also prolong QT interval. We aimed to explore the role of QTc interval prolongation in cirrhotic patients with upper gastrointestinal bleeding (UGIB). Overall, 167 patients were analyzed. QTc interval prolongation presented in 111 patients (66.5%). One hundred and seven patients (64.1%) suffered from acute UGIB. Results showed that RBC, Hb, ALB and calcium (Ca) were significantly lower, and DBIL, GGT, APTT, Child-Pugh score, MELD score and ALBI score were significantly higher in the prolongation group than those without QTc prolongation. AUROC of QTc was .699 (95%CI: .623-.768). In the acute UGIB subgroup, AUROC of QTc was .478 (95%CI: .347-.611). In the HBV subgroup, AUROC of QTc was .722 (95%CI: .616-.812). QTc interval prolongation was prevalent in cirrhotic patients with UGIB and correlated with liver dysfunction. QTc might not be a valid predictor of in-hospital mortality.
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Affiliation(s)
- Min Ou
- Department of Cardiovascular Medicine, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yin Tian
- Department of Gastroenterology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Guoqiang Zhuang
- Department of Cardiovascular Medicine, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Ying Peng
- Department of Gastroenterology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China; Cholestatic Liver Diseases Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
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Prolonged QT-interval in cirrhosis: is it reversible? Int J Cardiol 2020; 329:113-114. [PMID: 33279590 DOI: 10.1016/j.ijcard.2020.11.069] [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] [Received: 11/23/2020] [Accepted: 11/30/2020] [Indexed: 11/23/2022]
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Kapoor N, Mehta V, Singh B, Karna R, Kumar S, Kar P. Prevalence of cirrhotic cardiomyopathy and its relationship with serum pro-brain natriuretic peptide, hepatorenal syndrome, spontaneous bacterial peritonitis, and mortality. Indian J Gastroenterol 2020; 39:481-486. [PMID: 33188455 DOI: 10.1007/s12664-020-01083-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aims at estimating the prevalence of cirrhotic cardiomyopathy in a cohort of cirrhosis patients in northern India using the World Congress of Gastroenterology 2005 criteria and its relationship with grades of cirrhosis, its complications, and all-cause mortality. METHODS This was a prospective study in which 53 cirrhosis patients underwent the 2D color Doppler, and tissue Doppler echocardiography. Echocardiography findings were compared with thirty age- and sex-matched healthy controls. Additionally, serum pro-brain natriuretic peptide (pro-BNP) and troponin-T levels were measured. Patients were followed up for 6 months to look for complications and mortality. RESULT 2D echocardiography findings revealed that diastolic cardiomyopathy with no gross systolic dysfunction was significantly prevalent in cirrhosis patients. Using the Montreal criteria, we found the incidence of diastolic cardiomyopathy to be 56.6%. Tissue Doppler echocardiography findings were also correlated. Diastolic dysfunction correlated with the severity of cirrhosis, and patients with higher Child score had more diastolic dysfunction. Serum pro-BNP levels and QTc interval were also higher in patients with diastolic dysfunction. On survival analysis, patients with cirrhotic cardiomyopathy had shorter survival and greater frequency of encephalopathy and hepatorenal syndrome (HRS) episodes as compared with cirrhotic patients without cardiomyopathy, though the differences were not statistically significant. CONCLUSION The study showed that diastolic dysfunction was highly prevalent (56.6% of the study population) in cirrhosis patients. QTc interval and pro-BNP were also significantly raised. Also, complications of cirrhosis like HRS, spontaneous bacterial peritonitis, and hepatic encephalopathy were more common in the cirrhotic cardiomyopathy group.
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Affiliation(s)
- N Kapoor
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - V Mehta
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - B Singh
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - R Karna
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - S Kumar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - P Kar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India.
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Abstract
PURPOSE OF REVIEW Cirrhotic cardiomyopathy is a syndrome of depressed cardiac function in patients with cirrhosis. We aimed to review the historical background, pathophysiology and pathogenesis, diagnostic definitions, clinical relevance, and management of this syndrome. RECENT FINDINGS An inflammatory phenotype underlies the pathogenesis: gut bacterial translocation with endotoxemia stimulates cytokines and cardiodepressant factors, such as nitric oxide and endocannabinoids. Cardiomyocyte plasma membrane biochemical and biophysical changes also play a pathogenic role. These factors lead to impaired beta-adrenergic function. Proposed new echocardiographic criteria for the diagnosis of cirrhotic cardiomyopathy include systolic global longitudinal strain and indices of diastolic dysfunction. Cardiac dysfunction participates in the pathogenesis of hepatorenal syndrome and increased morbidity/mortality of cirrhotic patients to hemorrhage, infection, and surgery, including liver transplantation. There is no specific treatment, although β-adrenergic blockade and supportive management have been proposed, but it needs further study. Cirrhotic cardiomyopathy is a clinically relevant syndrome afflicting patients with established cirrhosis. Optimum management remains unclear, and further study is needed in this area.
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Affiliation(s)
- Ki Tae Yoon
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.,Liver Center, Department of Internal Medicine, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongnam, 50612, South Korea
| | - Hongqun Liu
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Samuel S Lee
- Liver Unit, University Calgary Cumming School of Medicine, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
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Arya S, Deshpande H, Belwal S, Sharma P, Sadana P, Chandrakant, Rahman F, Gupta M, Uniyal B. Association between cardiac dysfunction, arrhythmias and chronic liver diseases: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Toma L, Stanciu AM, Zgura A, Bacalbasa N, Diaconu C, Iliescu L. Electrocardiographic Changes in Liver Cirrhosis-Clues for Cirrhotic Cardiomyopathy. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:68. [PMID: 32050594 PMCID: PMC7073951 DOI: 10.3390/medicina56020068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/02/2020] [Accepted: 02/03/2020] [Indexed: 12/15/2022]
Abstract
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy.
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Affiliation(s)
- Letitia Toma
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Adriana Mercan Stanciu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
| | - Anca Zgura
- Chemotherapy Department, OncoFort Hospital, 022328 Bucharest, Romania;
| | - Nicolae Bacalbasa
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
| | - Camelia Diaconu
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 022328 Bucharest, Romania;
| | - Laura Iliescu
- Department of Internal Medicine II, Fundeni Clinical Institute, 022328 Bucharest, Romania; (L.T.); (A.M.S.)
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania;
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Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020; 24:1251-1255. [PMID: 33446981 PMCID: PMC7775933 DOI: 10.5005/jp-journals-10071-23695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objectives Impairment of cardiac function and arrhythmias often coexist in patients with liver diseases. Many studies have proved this coexistence and put forward various theories toward its pathophysiology. This narrative review tries to find the answers with supporting evidence on five main questions: Materials and methods Clinical evidence was obtained by using search engines, namely, Cochrane Library, PubMed, and Google Scholar. Studies published in journals in the English language, between January 1969 and December 2019, which mentioned the relationship between cardiac arrhythmia and liver disease, were included. We used the keywords: jaundice, bilirubin, arrhythmia, ECG, QTc interval, QT dispersion, liver, and cirrhosis. Relevant animal or human studies answering the five main questions were extracted and reviewed. Conclusion The evidence included in our review sheds light on the fact that approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy (CC) and there has been an association between liver abnormalities and cardiac pathology. The present review also supports that there exists a strong association between high levels of serum bilirubin levels and cardiac arrhythmias, QTc value can be relied upon as a risk factor for predicting imminent arrhythmias, and that it is associated with mortality. Its basic pathophysiology can be explained by the potential action of bile acids in prolonging the QT interval. It also causes cardiac hypertrophy and apoptosis of cardiomyocytes leading to cardiac dysfunction. How to cite this article Arya S, Kumar P, Tiwari B, Belwal S, Saxena S, Abbas H. What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review. Indian J Crit Care Med 2020;24(12):1251–1255.
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Affiliation(s)
- Sanjeev Arya
- Department of Critical Care, Max Super Specialty Hospital (Previously), Dehradun, India
| | - Prashant Kumar
- Department of Critical Care, Kailash Hospital, Noida, Uttar Pradesh, India
| | - Bhuwan Tiwari
- Department of Cardiology, Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India
| | - Shantanu Belwal
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Sanjay Saxena
- Department of Critical Care, Max Super Specialty Hospital, Dehradun, India
| | - Haider Abbas
- Department of ER and Critical Care, King Georges Medical University, Lucknow, Uttar Pradesh, India
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Kazankov K, Jensen HK, Watson H, Vilstrup H, Bernardi M, Jepsen P. QT interval corrected for heart rate is not associated with mortality in patients with cirrhosis and ascites. Scand J Gastroenterol 2019; 54:1376-1378. [PMID: 31609144 DOI: 10.1080/00365521.2019.1677767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Konstantin Kazankov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Kjaerulf Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Hugh Watson
- Evotec ID, Lyon, France.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Mauro Bernardi
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Moaref A, Zamirian M, Mirzaei H, Attar A, Nasrollahi E, Bahramvand Y. Myocardial contractile dispersion: A new marker for the severity of cirrhosis? J Cardiovasc Thorac Res 2019; 11:147-151. [PMID: 31384410 PMCID: PMC6669422 DOI: 10.15171/jcvtr.2019.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 06/29/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction: Cirrhotic cardiomyopathy (CCM) develops in about half of all cirrhotic patients, affecting the long-term morbidity and mortality. Although some studies have shown an increased QT-interval in cirrhotic patients, no evidences of myocardial contractile and QT dispersion (QTd) changes are available. This study aimed to compare myocardial contractile dispersion (MCd), using tissue Doppler imaging (TDI), as well as QTd between cirrhotic patients and healthy individuals, investigating their associations with cirrhosis severity.
Methods: This prospective cross-sectional study was conducted on patients with confirmed liver cirrhosis and healthy individuals. Participants with structural heart disease, heart ventricular pacing, electrolyte abnormalities, using drugs affecting QT interval were excluded. All individuals underwent 2D echocardiography, and TDI by vivid E9 echo machine. MCd and QTd were considered as main outcomes. Chi-square, independent-sample t test, and Pearson correlation test, were used for statistical analyses by SPPS version 17.0. P value <0:05 was considered statistically significant.
Results: Sixty participants (40 male/20 female) with a mean age of 40.1 ± 7.1 years in two groups of cirrhotic patients (n=30) and healthy individuals (n=30) were studied. Both groups were statistically similar in terms of age (P = 0.31) and gender (P = 0.39). MCd and QTd of cirrhotic patients were significantly higher than healthy individuals (MCd: 41.0 ± 26.8 versus 27.6±18.1; P = 0.028; and QTd: 37.0 ± 22.1 versus 25.3 ± 8.9; P = 0.010). Cirrhotic patients with MELD score <15 had a lower MCd in comparison to score ≥15 (29.2 ± 13.8 versus 50.0 ± 31.1, P = 0.034).
Conclusion: Cirrhosis was associated with increased MCd, assessed by TDI. Also, MCd and QTd were associated with a higher MELD score. According to the results, it seems that MCd and QTd might be useful predictor of ventricular arrhythmia and negative prognostic factor in cirrhotic patients.
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Affiliation(s)
- Alireza Moaref
- Department of Cardiovascular Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Zamirian
- Department of Cardiovascular Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Mirzaei
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Attar
- Department of Cardiovascular Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Nasrollahi
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Yaser Bahramvand
- Students' Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
Cirrhosis with portal hypertension and related complications are associated with a high mortality. Excess of circulating vasodilators and cardiodepressive substances lead to a hyperdynamic circulation with changed myocardial structure and function. The entity cirrhotic cardiomyopathy seems to be involved in different aspects of hepatic decompensation, which focuses on new targets of treatment. Areas covered: This review deals with contemporary aspects of cirrhotic cardiomyopathy, and the literature search was undertaken by PubMed with 'cirrhotic' and 'cardiomyopathies' as MeSH Terms. Cirrhotic cardiomyopathy is defined as the presence of systolic and diastolic dysfunction and electrophysiological abnormalities. The diagnosis is based on contemporary Doppler/Echocardiography measurements or quantitative magnetic resonance imaging. Cirrhotic cardiomyopathy is independent of the etiology of the liver disease but related to severity and survival. Expert commentary: The outcome of invasive procedures and liver transplantation is influenced by the presence of cardiac dysfunction. Therefore, a cautious cardiac evaluation should be included in the patient evaluation prior to liver transplantation. Liver transplantation ameliorates most of the abnormalities seen in cirrhotic cardiomyopathy, but no specific treatment can yet be recommended.
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Affiliation(s)
- Søren Møller
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Karen V Danielsen
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark.,b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Signe Wiese
- a Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark.,b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Jens D Hove
- c Department of Cardiology, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
| | - Flemming Bendtsen
- b Gastroenterology Unit, Medical Division, Hvidovre Hospital , University of Copenhagen , Hvidovre , Denmark
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Chokesuwattanaskul R, Thongprayoon C, Bathini T, O'Corragain OA, Sharma K, Preechawat S, Wijarnpreecha K, Kröner PT, Ungprasert P, Cheungpasitporn W. Epidemiology of atrial fibrillation in patients with cirrhosis and clinical significance: a meta-analysis. Eur J Gastroenterol Hepatol 2019; 31:514-519. [PMID: 30451705 DOI: 10.1097/meg.0000000000001315] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The epidemiology of atrial fibrillation (AF) in patients with cirrhosis and its clinical significance remain unclear. This study aimed (i) to investigate the pooled prevalence and/or incidence of AF in patients with cirrhosis and (ii) to assess the mortality risk of AF in patients with cirrhosis. PATIENTS AND METHODS A literature search for studies that reported incidence of AF in patients with cirrhosis was carried out using Medline, Embase, and Cochrane Database from inception through July 2018. Pooled incidence with 95% confidence interval (CI) was calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42018102664). RESULTS Seven cohort studies including 385 866 patients with cirrhosis were identified. The pooled estimated prevalence of AF in patients with cirrhosis was 5.0% (95% CI: 2.8-8.6%). When studies that solely assessed patients undergoing transplant evaluation or on transplant waiting list were excluded, the pooled estimated prevalence of AF in patients with cirrhosis was 7.4% (95% CI: 3.5-15.2%). There was a significant association between AF and increased mortality risk in cirrhotic patients with a pooled odds ratio of 1.44 (95% CI: 1.36-1.53). CONCLUSION The overall estimated prevalence of AF among patients with cirrhosis is 5.0%. Our study demonstrates a statistically significant increased mortality risk in cirrhotic patients with AF.
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Affiliation(s)
- Ronpichai Chokesuwattanaskul
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society
| | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Oisin A O'Corragain
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York
| | - Somchai Preechawat
- Department of Medicine, Division of Cardiology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society
| | | | - Paul T Kröner
- Division of Gastroenterology, Mayo Clinic, Jacksonville, Florida
| | - Patompong Ungprasert
- Department of Research and Development, Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. ACTA ACUST UNITED AC 2019; 52:e7809. [PMID: 30785477 PMCID: PMC6376321 DOI: 10.1590/1414-431x20187809] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.
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Affiliation(s)
- M V H Carvalho
- Departamento de Cirurgia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - P C Kroll
- Hospital de Transplante E.J. Zerbini, São Paulo, SP, Brasil
| | - R T M Kroll
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - V N Carvalho
- Hospital Municipal Dr. Mario Gatti, Campinas, SP, Brasil
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Lee SK, Song MJ, Kim SH, Ahn HJ. Cardiac diastolic dysfunction predicts poor prognosis in patients with decompensated liver cirrhosis. Clin Mol Hepatol 2018; 24:409-416. [PMID: 30145855 PMCID: PMC6313020 DOI: 10.3350/cmh.2018.0034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/26/2018] [Accepted: 06/29/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Left ventricular diastolic dysfunction (LVDD) is an early manifestation of cardiac dysfunction in patients with liver cirrhosis (LC). However, the effect of LVDD on survival has not been clarified, especially in decompensated LC. METHODS We prospectively enrolled 70 patients with decompensated LC, including ascites or variceal bleeding, at Daejeon St. Mary's Hospital from April 2013 to April 2015. The cardiac function of these patients was evaluated using 2D echocardiography with tissue Doppler imaging. The diagnosis of LVDD was based on the American Society of Echocardiography guidelines. The primary endpoint was overall survival. RESULTS Forty-four patients (62.9%) had LVDD. During follow-up (22.3 months), 18 patients died (16 with LVDD and 2 without LVDD). The survival rate was significantly lower in patients with LVDD than in those without LVDD (31.1 months vs. 42.6 months, P=0.01). In a multivariate analysis, the Child-Pugh score and LVDD were independent predictors of survival. Moreover, patients with a ratio of early filling velocity to early diastolic mitral annular velocity (E/e') ≥ 10 (LVDD grade 2) had lower survival than patients with E/e' ratio < 10. CONCLUSION The presence of LVDD is associated with poor survival in patients with decompensated LC. Therefore, it may be important to monitor and closely follow LVDD patients.
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Affiliation(s)
- Soon Kyu Lee
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Myeong Jun Song
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Seok Hwan Kim
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Hyo Jun Ahn
- Division of Hepatology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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Lee SH, Park M, Park KM, Gwag HB, Park J, Kim J, Choi GS, Lee SK, Kim GS. Corrected QT interval on the electrocardiogram after liver transplantation: Surrogate marker of poor clinical outcomes? PLoS One 2018; 13:e0206463. [PMID: 30365563 PMCID: PMC6203397 DOI: 10.1371/journal.pone.0206463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/13/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Prolongation of corrected QT interval (QTc) on the electrocardiogram is associated with cardiac arrhythmia and sudden death. Changes in the QTc (corrected QT) interval before and after liver transplantation (LT) for the treatment of liver cirrhosis (LC) and its association with clinical outcomes have not been fully evaluated. METHODS From January 2011 to May 2016, consecutive 516 consecutive recipients were enrolled into LT registry and the median follow-up was 31 months (IQR 12-52). Patients with an available electrocardiogram before LT and 1 month after from LT were analyzed. Patients were divided into 2 groups according to prolonged QTc interval. The patient groups were analyzed separately according whether the electrocardiogram was preoperative or postoperative. The primary outcome was all-cause death during the follow-up period. RESULTS A total of 283 patients were enrolled in the study. In the preoperative QTc prolongation group, there was not a significant rate difference in all-cause mortality in multivariate analysis (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.53-1.66; P = 0.26). However, in the postoperative QTc prolongation group, mortality was significantly increased (HR, 1.78; 95%CI, 1.05-3.03; P = 0.03) in patients who underwent LT. CONCLUSION In patients who underwent LT for LC, postoperative QTc prolongation on ECG, rather than preoperative, is associated with mortality. Larger clinical trials are needed to support this finding.
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Affiliation(s)
- Seung-Hwa Lee
- Department of Medicine, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myungsoo Park
- Department of Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
| | - Kyoung-min Park
- Department of Medicine, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Hye-bin Gwag
- Department of Medicine, Heart, Stroke and Vascular Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Q-T Interval Prolongation in Patients with Liver Cirrhosis. CURRENT HEALTH SCIENCES JOURNAL 2018; 44:274-279. [PMID: 30647948 PMCID: PMC6311219 DOI: 10.12865/chsj.44.03.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023]
Abstract
Liver cirrhosis (LC) is the end stage of chronic liver disease characterized by the appearance of extensive fibrosis and regeneration nodes associated with hepatocyte necrosis in liver but also by the reshuffling of hepatic architecture. The triad consisting of hepatic parenchymal necrosis, regeneration and scarring is always present regardless of the type of clinical manifestation. The Child-Pugh-Turcotte classification dates back more than 30 years and has been widely used in diagnosing and assessing the severity of liver cirrhosis. This is preferred due to a low degree of complexity and a good predictive value. Prolongation of the QT interval on the electrocardiogram is common, with a prevalence exceeding 60% in patients with advanced stage of cirrhosis. In these cases, beta blockers and antiarrhythmics should be avoided or used with caution and with close QT interval monitoring. Changes in heart rate and Q-T interval are new entities in cirrhosis complications. A prolonged Q-T interval in chronic liver disease could lead to ventricular arrhythmias and sudden death. There is no report on heart rate and Q-T interval disorders in our area.
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Günay N, Erdem Ş, Güvenç TS, Bulur A, Özdil K, Hasdemir H, Uyan C. Morphologic and Functional Changes in Right-Sided Cardiac Chambers in Patients With Chronic Liver Disease and Normal Pulmonary Artery Pressure. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1681-1691. [PMID: 29266366 DOI: 10.1002/jum.14516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/23/2017] [Accepted: 09/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To investigate the effects of chronic liver disease (CLD) on the structural and functional characteristics of right-sided heart chambers in patients with normal pulmonary artery pressure. METHODS Fifty-one patients with known CLD but without pulmonary hypertension or other cardiovascular conditions were consecutively enrolled, along with 25 age- and sex-matched participants. Patients with CLD were classified according to the Model of End-Stage Liver Disease score and Child-Pugh classification. Right ventricular (RV) and right atrial (RA) dimensions, indices of RV systolic/diastolic function, and myocardial strain were measured by standard echocardiographic methods. RESULTS Patients in the study group had similar RV end-diastolic, end-systolic, and RA dimensions compared to controls. Similarly, neither the conventional indices of RV systolic/diastolic function nor the strain imaging findings were different between groups (P > .05). Only RV free wall thickness was significantly higher in the study group (mean ± SD, 4.15 ± 0.64 versus 3.75 ± 0.37 mm; P < .001). Right ventricular end-diastolic diameter (P = .018; r = 0.334) and RA area (P = .017; r = 0.335) had a significant correlation with RV free wall thickness in patients with CLD. Patients treated with beta blockers were found to have a significant reduction in mean RV free wall strain compared to patients who did not receive beta blocker treatment (-20.37 ± 6.6 versus -24.07 ± 6.52; P = .04). CONCLUSIONS Patients with CLD had increased RV free wall thickness despite normal systolic pulmonary pressure, presumably secondary to cirrhotic cardiomyopathy. In the absence of pulmonary hypertension, however, cirrhotic cardiomyopathy did not cause impaired RV systolic or diastolic function.
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Affiliation(s)
- Nuran Günay
- Departments of Cardiology, Ümraniye Research and Tranining Hospital, Istanbul, Turkey
| | - Şükran Erdem
- Departments of Cardiology, Ümraniye Research and Tranining Hospital, Istanbul, Turkey
| | - Tolga Sinan Güvenç
- Department of Cardiology, Dr Siyami Ersek Cardiovascular and Thoracic Surgery Research and Training Hospital, Istanbul, Turkey
| | - Atilla Bulur
- Departments of Gastroenterology, Ümraniye Research and Tranining Hospital, Istanbul, Turkey
| | - Kamil Özdil
- Departments of Gastroenterology, Ümraniye Research and Tranining Hospital, Istanbul, Turkey
| | - Hakan Hasdemir
- Department of Cardiology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Cihangir Uyan
- Departments of Cardiology, Ümraniye Research and Tranining Hospital, Istanbul, Turkey
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Cho HS, Kim WJ, Lee BA, Cho J, Shin WJ, Hwang GS. Pretransplant increases in left ventricular volume and mass are associated with QT prolongation during pediatric liver transplantation. Pediatr Transplant 2018; 22:e13237. [PMID: 29908011 DOI: 10.1111/petr.13237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 11/27/2022]
Abstract
Structural alterations in the cirrhotic heart may contribute to electromechanical abnormalities, represented by QT prolongation. The aim of this study was to investigate the changes in QTc according to the operative stage during pediatric LT and to identify which baseline echocardiographic parameters were associated with intraoperative QTc prolongation. Data were evaluated from 39 children undergoing LT for chronic liver disease (median age 9 months). In 19 patients (48.7%), baseline QTc was prolonged ≥440 ms (462 ± 19 ms). Through the period of post-reperfusion, QTI, QTc, and JTI progressively increased, although values partially recovered toward the end of surgery. High LVMI (≥82.51 g/m2 ) was associated with baseline QTc ≥ 440 ms (OR = 1.034, P = .032). In the 5 minutes post-reperfusion stage, marked QTc prolongation (defined as QTc ≥ 500 ms; n = 24, 61.5%) was significantly associated with high EDVI (OR = 1.060, P = .027) and SVI (OR = 1.075, P = .026). In children with chronic liver disease, increased ventricular volumes and mass may increase the risk of QTc prolongation during LT, suggesting that repolarization abnormalities might be contributed by structural changes characteristic of cirrhotic cardiomyopathy.
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Affiliation(s)
- Hyun-Seok Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wook-Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Laboratory for Cardiovascular Dynamics and Signal Processing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byungdoo Andrew Lee
- Public Health Care Doctor, Hoengseong County Public Health Care Center, Gangwon-Do, Korea
| | - Junki Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Laboratory for Cardiovascular Dynamics and Signal Processing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Laboratory for Cardiovascular Dynamics and Signal Processing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kwon HM, Hwang GS. Cardiovascular dysfunction and liver transplantation. Korean J Anesthesiol 2018; 71:85-91. [PMID: 29619780 PMCID: PMC5903113 DOI: 10.4097/kjae.2018.71.2.85] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/22/2017] [Accepted: 10/12/2017] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular complications have emerged as the leading cause of death after liver transplantation, particularly among those with advanced liver cirrhosis. Therefore, a thorough and accurate cardiovascular evaluation with clear comprehension of cirrhotic cardiomyopathy is recommended for optimal anesthetic management. However, cirrhotic patients manifest cardiac dysfunction concomitant with pronounced systemic hemodynamic changes, characterized by hyperdynamic circulation such as increased cardiac output, high heart rate, and decreased systemic vascular resistance. These unique features mask significant manifestations of cardiac dysfunction at rest, which makes it difficult to accurately evaluate cardiovascular status. In this review, we have summarized the current knowledge of heart and liver interactions, focusing on the usefulness and limitations of cardiac evaluation tools for identifying high-risk patients.
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Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Rimbaş RC, Baldea SM, Guerra RDGA, Visoiu SI, Rimbaş M, Pop CS, Vinereanu D. New Definition Criteria of Myocardial Dysfunction in Patients with Liver Cirrhosis: A Speckle Tracking and Tissue Doppler Imaging Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:562-574. [PMID: 29306590 DOI: 10.1016/j.ultrasmedbio.2017.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/25/2017] [Accepted: 11/20/2017] [Indexed: 06/07/2023]
Abstract
There are no clear recommendations regarding cirrhotic cardiomyopathy (CC) evaluation in patients with pre-transplant liver cirrhosis. The roles of new methods, tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in the diagnosis and prognosis of cirrhotic cardiomyopathy remain controversial. We investigated the utility of TDI/STE parameters in cirrhotic cardiomyopathy diagnosis and also in predicting mortality in patients with liver cirrhosis. Left/right ventricular function was studied using conventional TDI (velocities) and STE (strain/strain rate). We assessed left ventricular diastolic dysfunction, graded into four new classes (I/Ia/II/III). Serum NTproBNP (N-terminal prohormone of brain natriuretic peptide), troponin I, β-crosslaps, QTc interval, arterial compliance and endothelial function were measured. Liver-specific scores (Child-Pugh, MELD, MELDNa) were computed. There was a 1-y follow-up visit to determine mortality. We observed resting biventricular diastolic myocardial dysfunction, not presently included in the definition of cirrhotic cardiomyopathy. We provided an improved characterization of cardiac dysfunction in patients with liver cirrhosis. This might change the current definition. However, the utility of STE/TDI parameters in predicting long-term mortality in patients with liver cirrhosis remains controversial.
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Affiliation(s)
- Roxana Cristina Rimbaş
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Sorina Mihăilă Baldea
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | | | - Mihai Rimbaş
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Corina Silvia Pop
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Gastroenterology Department, University and Emergency Hospital, Bucharest, Romania
| | - Dragoş Vinereanu
- Cardiology Department, University and Emergency Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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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: 104] [Impact Index Per Article: 14.9] [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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Lee H, Choi EK, Rhee TM, Lee SR, Lim WH, Kang SH, Han KD, Cha MJ, Oh S. Cirrhosis is a risk factor for atrial fibrillation: A nationwide, population-based study. Liver Int 2017; 37:1660-1667. [PMID: 28432810 DOI: 10.1111/liv.13459] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 04/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Information is lacking regarding whether cirrhosis is associated with atrial fibrillation development. We aimed to investigate the incidence and clinical significance of atrial fibrillation in cirrhotic patients. METHODS Cirrhotic patients (n=3596; mean age, 54.7±12.3 years; male, 72.5%) without previous atrial fibrillation were selected from the Korean National Health Insurance Service National Sample Cohort database between 2004 and 2008. Age- and sex-matched controls (n=17 980) were randomly sampled in a 5:1 ratio from non-cirrhotic individuals. Both cohorts were followed up for incident atrial fibrillation and death until 2013. RESULTS During 9 years of follow-up, atrial fibrillation was newly detected in 113 (3.1%) cirrhosis patients and 385 (2.1%) controls (incidence: 3.48 and 2.16 per 1000 person-years respectively). Cirrhotic patients were at higher risk for atrial fibrillation development compared to controls (hazard ratio, 1.46; 95% confidence interval, 1.18-1.80) after multivariate adjustment. On subgroup analysis, cirrhosis increased the risk for atrial fibrillation, especially in younger (age younger than 65 years) men without comorbidities (CHA2 DS2 -VASc score, 0). Cirrhotic patients showed increased overall mortality compared to controls (hazard ratio, 4.80; 95% confidence interval, 4.47-5.15) as well as increased cardiovascular mortality (hazard ratio, 1.37; 95% confidence interval, 1.07-1.75). However, there was no significant association between development of atrial fibrillation and increased mortality in cirrhosis patients (P=.188 and .260). CONCLUSIONS Cirrhosis was an independent risk factor for atrial fibrillation development, especially in younger, otherwise healthy men, stressing the importance of cardiac assessment in cirrhotic patients. Meanwhile, atrial fibrillation development in cirrhosis patients was not associated with increased mortality.
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Affiliation(s)
- HyunJung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tae-Min Rhee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - So-Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo-Hyun Lim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Si-Hyuck Kang
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kyung-Do Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Jin Cha
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Santeusanio AD, Dunsky KG, Pan S, Schiano TD. The Impact of Cirrhosis and Prescription Medications on QTc Interval Before and After Liver Transplantation. J Pharm Pract 2017; 32:48-53. [PMID: 29092657 DOI: 10.1177/0897190017737896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND: Higher rates of corrected QT (QTc) prolongation have been reported in patients with cirrhosis. The impact of liver transplantation and prescription medications on the natural history of QTc prolongation has yet to be well characterized. METHODS: This was a single-center review of patients receiving (group 1) or listed for (group 2) a liver transplant during 2014. Patients in group 1 were followed prospectively from the date of transplantation to assess rates of QTc normalization posttransplant. In group 2, patients were evaluated from the date of listing up until December 2015 to assess the prevalence of QTc prolongation among liver transplant candidates. RESULTS: In group 1, 22 (75.9%) patients with QTc intervals >460 milliseconds at the time of transplant established normal baseline QTc intervals following transplantation. The median time to this QTc normalization was 17 days. In group 2, 30 (16.9%) patients had at least 1 documented QTc interval >500 milliseconds with prevalence rates of 42.9%, 19.0%, and 10.2% in patients with natural model of end-stage liver disease scores of >30, 16 to 30, and <16, respectively ( P < .01). Overall, 49.4% of patients in group 1 and 47.5% of patients in group 2 were prescribed QTc prolonging medications. CONCLUSION: QTc prolongation will resolve following transplantation in the majority of patients and generally occurs within the first several weeks. Among the listed liver transplant candidates, higher rates of clinically significant QTc prolongation may be observed in patients with more severe underlying cirrhosis. QTc prolonging medications are commonly prescribed in this population and warrant monitoring following initiation.
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Affiliation(s)
| | - Kevin G Dunsky
- 2 Department of Cardiology, Mount Sinai Hospital, New York, NY, USA
| | - Stephanie Pan
- 3 Department of Population Health Science and Policy, Mount Sinai Hospital, New York, NY, USA
| | - Thomas D Schiano
- 4 Department of Hepatology, Mount Sinai Hospital, New York, NY, USA
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Salgado AA, Barbosa PRB, Ferreira AG, Reis CADSS, Terra C. Prognostic Value of a New Marker of Ventricular Repolarization in Cirrhotic Patients. Arq Bras Cardiol 2017; 107:523-531. [PMID: 28558079 PMCID: PMC5210456 DOI: 10.5935/abc.20160181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 06/08/2016] [Indexed: 01/06/2023] Open
Abstract
Background There is still debate about the relationship between changes in ventricular
repolarization on the surface electrocardiogram and cirrhosis severity. Objective To study the relationship between variables related to ventricular
repolarization and the clinical severity of the cirrhotic disease. Methods We selected 79 individuals with hepatic cirrhosis, classified according to
the Child-Pugh-Turcotte criteria (Child A, B, and C). We measured the QT and
corrected QT (QTc) intervals, and the interval between the peak and the end
of the T wave (TpTe), and we identified their minimum, maximum, and mean
values in the 12-lead electrocardiogram. We also calculated the dispersion
of the QT (DQT) and QTc (DQTc) intervals. Results In 12 months of clinical follow-up, nine subjects underwent hepatic
transplantation (Child A: 0 [0%]; Child B: 6 [23.1%]; Child C: 3 [18.8%]; p
= 0.04) and 12 died (Child A: 3 [12.0%]; Child B: 4 [15.4%]; Child C: 5
[31.3%]; p = 0.002). No significant differences were observed between the
cirrhotic groups related to the minimum, maximum, and mean values for the
QT, QTc, TpTe, DQT, and DQTc intervals. A minimum TpTe interval ≤ 50
ms was a predictor for the composite endpoints of death or liver
transplantation with a sensitivity of 90% and a specificity of 57% (p =
0.005). In the Cox multivariate analysis, the Child groups and a minimum
TpTe of ≤ 50 ms were independent predictors of the composite
endpoints. Conclusion The intervals QT, QTc, DQT, DQTc, and TpTe have similar distributions between
different severity stages in cirrhotic disease. The TpTe interval proved to
be a prognostic marker in subjects with cirrhosis, regardless of disease
severity (NCT01433848).
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Affiliation(s)
- Angelo Antunes Salgado
- Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro, RJ, Brazil
| | | | | | | | - Carlos Terra
- Hospital Universitário Pedro Ernesto, Universidade Estadual do Rio de Janeiro, RJ, Brazil
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