Hepato-cardiac disorders

Table 1 Proposal for diagnostic and supportive criteria for cirrhotic cardiomyopathy agreed upon at a working party held at the 2005 World Congress of Gastroenterology

A working definition of cirrhotic cardiomyopathy

A cardiac dysfunction in patients with cirrhosis characterised by impaired contractile responsiveness to stress and/or altered diastolic relaxation with electrophysiological abnormalities in the absence of other known cardiac disease

Diagnostic criteria

Systolic dysfunction

Blunted increase in cardiac output with exercise, volume challenge or pharmacological stimuli

Resting EF < 55%

Diastolic dysfunction

E/A ratio < 1.0 (age-corrected)

Prolonged deceleration time (> 200 ms)

Prolonged isovolumetric relaxation time (> 80 ms)

Supportive criteria

Electrophysiological abnormalities

Abnormal chronotropic response

Electromechanical uncoupling/dyssynchrony

Prolonged QTc interval

Enlarged left atrium

Increased myocardial mass

Increased BNP and pro-BNP

Increased troponin I

BNP: Brain natriuretic peptide; E/A: Early diastolic/atrial filling ratio; EF: Left-ventricular ejection fraction.

Table 2 Comparison between acute and chronic hepatic complications of cardiac failure

	Chronic congestive hepatopathy	Acute ischemic hepatitis
Aetiology	Chronic heart failure	Acute heart failure
Pathophysiology	Perisinusoidal edema	Tissue hypoxia
	Increased lymph flow	Zone 3 necrosis
	Zone 3: alternating necrosis and hemorrhage
	Sinusoidal thrombosis
Manifestations	Right hypochondrial pain	Asymptomatic or nonspecific
	Edema, ascites, jaundice	(nausea, vomiting, jaundice, right hypochondrial pain)
Laboratory data
Bilirubin	Mild increase	Marked elevation
ALT and AST	Normal mild elevation	Marked elevation
LDH	Normal or mild elevation	Marked elevation
Prothrombin time	Prolonged	Normal or prolonged
ALP	Normal or mild elevation	Increased
Albumin	Hypoalbuminemia	Normal
Traetment	ACE inhibitors	Oxygen therapy
	b-blockers	Avoid precipitating factors
	Diuretic	Inotropic agents with caution
	Amiodarone	Vasopressor with caution
	Statins with caution	Diuretics in hypervolemia
Prognosis	Slowly progressive course	Benign and usually self limited

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; LDH: Lactic dehydrogenase; ALP: Alkaline phosphatase; ACE: Angiotensin-converting enzyme.

Table 3 Diseases affecting both the liver and the heart concomitantly

	Hepatic manifestations	Cardiac manifestations
Congenital
Allagile syndrome	Cholestasis	Congenital heart defects
Situs Inversus totalis	Concerns with liver or heart transplantation
Infections
Sepsis	Acute liver failure	Acute heart failure
Hepatitis C	Hepatitis	Myocarditis, cardiomyopathy
Cytomegalovirus	Hepatiitis	Myopericarditis
HIV	Hepatitis, granuloma	Myocarditis , cardiomyopathy
Malaria	Hepatic necrosis	Cariac failure
Dengue fever	Hepatic necrosis	Myocarditis
Amebiasis	Hepatitis, hepatic abscess	Pericarditis, effusion
Metabolic
Wilson disease	Cirrhosis, hepatitis	Left ventricular remodeling
Hemochromatosis	Cirrhosis, hepatitis	Cardiomyopathy
Systemic
SLE	Steatosis, hepatomegaly	Endocarditis, pericarditis
Amyloidosis	Hepatomegaly, cholestasis	Cardiomyopathy
Sarcoidosis	Granuloma, cholestasis	Conduction defects, HF
Chronic alcoholism	Cirrhosis	Cariomyopathy
Autoimmune
Grave’s disease	Hepatitis, cholestasis	HF
Autoimmune hepatitis	Hepatitis, cirrhosis	Carditis

HF: Heart failure.