Cardiovascular involvement in patients with liver cirrhosis
Article Outline
Cardiovascular abnormalities often result in structural and functional abnormalities in a number of organ systems in human body. Abnormalities in other systems can also result in overt or sub-clinical abnormalities in cardiovascular system. Several genetic, biochemical, toxic and infectious conditions involve multiple organ systems to varying degrees. Detection of abnormalities in one organ system often results in a search for abnormalities in other organ systems. Hemochromatosis, amyloidosis, hypertension and chronic alcohol abuse are common examples of conditions where a thorough evaluation often reveals multi-system involvement irrespective of the primary mode of presentation.
In a study in this issue of the Journal, Torregrosa et al. investigated the presence of abnormalities in cardiovascular system in patients with liver cirrhosis by performing echocardiography and rest and exercise equilibrium radionuclide angiocardiography [1]. Patients with overt cardiovascular abnormalities such as congestive heart failure, hypertension and symptomatic coronary artery disease were excluded. Subtle, sub-clinical abnormalities were common in these patients. These abnormalities comprised of a slight increase in left ventricular wall thickness and left ventricular mass; higher resting stroke volume, left ventricular ejection fraction and cardiac output; failure of left ventricular ejection fraction to increase with semi-supine exercise; and impaired overall exercise capacity. These abnormalities were more common in patients with ascites. These abnormalities regressed following successful liver transplantation. Interestingly, these abnormalities were equally common in patients with non-alcoholic and alcoholic liver cirrhosis.
Cardiovascular complications are the major source of peri-operative morbidity and mortality in patients undergoing major non-cardiac surgery and also for subsequent long-term prognosis in these patients [2], [3]. Therefore, a thorough cardiovascular evaluation is a routine in patients undergoing major non-cardiac surgery. Detection of any abnormality on initial screening with non-invasive techniques such as echocardiography or exercise or pharmacological stress perfusion imaging often leads to further invasive evaluation with coronary angiography [2], [3], [4]. In this context, the results of this study are important. This study shows that subtle cardiovascular abnormalities are common in patients with liver cirrhosis even when patients with known cardiovascular disease, hypertension or diabetes are excluded. However, it is unclear whether these subtle abnormalities are non-specific being simply a reflection of poor general state of health, anemia, malnutrition and ascites, or they are a direct consequence of liver cirrhosis. It is also unclear whether these abnormalities have any clinical, therapeutic or prognostic relevance. The authors have provided no data whether detection of these abnormalities influenced the selection or suitability of these patients for liver transplantation and whether there were any differences in the peri-operative morbidity, mortality and rate of recovery of patients with these abnormalities versus those with no such abnormalities. Perhaps a small sample size would preclude a reliable analysis of these data from this study. If there are no differences in the peri-operative and or long-term cardiovascular morbidity and mortality based upon the detection of these abnormalities, this would be supportive of the speculation that these are merely non-specific abnormalities with no implications from a therapeutic and management aspect. The fact, that these abnormalities were equally common in patients with alcoholic and non-alcoholic liver cirrhosis, would further lend support to the speculation of them being non-specific, because patients with known cardiac and other systemic diseases were excluded.
True prevalence of the occurrence, nature and clinical implications of cardiovascular abnormalities in patients with liver cirrhosis can only be studied using a very large and randomly selected group of patients with liver cirrhosis who undergo a detailed cardiovascular assessment including myocardial perfusion imaging, echocardiography and exercise testing. The evaluation must include the presence of risk factors for coronary artery disease and other possible factors, which can impact cardiac function such as anemia, biochemical abnormalities, nutritional status and pulmonary disease. This study can provide information about the presence of overt symptomatic as well sub-clinical abnormalities in patients with liver cirrhosis of different etiologies and varying severities. Furthermore, this study can also provide information about the impact of the subtle cardiovascular abnormalities such as those described by Torregrosa et al. on the progression of liver disease as well as their impact on the long term survival and surgical outcome in these patients and whether they do or do not warrant any specific therapeutic measures.
The results of this study are important and clinically relevant in that sub-clinical abnormalities in echocardiography and exercise radionuclide angiocardiography are common in patients with advanced liver cirrhosis who are undergoing evaluation for liver transplantation even in the absence of any overt clinical features of coronary artery disease or cardiomyopathy. These subtle abnormalities generally reverse after successful liver transplantation. Until the availability of further data, the presence of these abnormalities alone does not warrant further invasive cardiovascular evaluation or work-up or any different peri-operative monitoring or management strategy.
References
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- . Comparison of dipyridamole and exercise stress echocardiography for detection of coronary artery disease (a meta-analysis). Am J Cardiol. 2001;15:1193–1196
PII: S0168-8278(04)00527-6
doi:10.1016/j.jhep.2004.11.011
© 2004 European Association for the Study of the Liver. Published by Elsevier Inc. All rights reserved.
