Presence of any degree of coronary artery disease among liver transplant candidates is associated with increased rate of post‐transplant major adverse cardiac events

Abstract

Heart disease is the leading cause of death in the US general population with the overwhelming majority of these deaths due to coronary artery disease (CAD), the latter a condition with increasing prevalence in patients with chronic liver disease. 1,2 Cardiovascular disease (CVD), including CAD, is a known major cause of morbidity and mortality among liver transplant recipients (LTR), and severity of CAD among liver transplant candidates (LTC) has been demonstrated to impact post-LT mortality. 3-8 However, the impact of CAD, particularly non-obstructive CAD, among LTC on post-LT major adverse cardiac events (MACE) and long-term outcomes remains poorly defined. To assess CVD risk, all LTC undergo some form of screening for the presence of CAD; however, these screening measures typically consist of noninvasive methods that utilize traditional CAD risk factors or diagnostic imaging studies that are of limited predictive or diagnostic value in patients with advanced liver disease. 9-11 These

Use of Computed Tomography Coronary Calcium Score for Coronary Artery Disease Risk Stratification During Liver Transplant Evaluation

“…The applicability of coronary computed tomography angiography for evaluation of CAD in LT candidates is limited, therefore further research is required to standardized its use and to determine its prognostic role along with CAC. (35,36) When considering severe CAD (luminal stenosis ≥70%) as an endpoint in the whole cohort, CAC outperformed other strategies commonly used to assess CAD, including cardiac stress testing. Although DSE and SPECT are commonly used for cardiac J o u r n a l P r e -p r o o f evaluation of LT candidates, they have shown suboptimal to poor predictive usefulness.…”

A Meta‐Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

“…(8,52) Patel et al suggested the possibility of a fixed cardiac mortality that resulted from the cardiovascular strain during the transplant surgery, which is inevitable despite extensive pre-LT screening and intervention. (53) However, Patel et al and Satapathy et al reported no significant differences in overall mortality between pre-LT patients with or without CAD when obstructive CAD was properly revascularized prior to LT. (53,54) In addition, Skaro et al only reported 1 death among patients with obstructive CAD prior to LT, (55) whereas both Patel et al and Hughes et al reported no mortality in patients with obstructive CAD diagnosed prior to LT. (53,56) Notably, mortality analyses in the studies by Skaro et al and Hughes et al were likely limited by low mortality rates, and both studies demonstrated an increased risk for composite cardiac outcomes in patients diagnosed with obstructive CAD prior to LT. (55,56) Although there is a high prevalence of CAD diagnosis in pre-LT patients as displayed in this article, there might be a disconnect between cardiovascular outcomes after LT because of the relatively low prevalence of such outcomes. As such, an optimal medical therapy for patients with CAD prior to LT should be the cornerstone of most LT programs as corroborated by Patel et al and Satapathy et al (53,54) stRenGtHs AnD liMitAtions…”

Cardiac risk stratification of the liver transplant candidate: A comprehensive review

“…Epidemiology: Patients with ESLD and concomitant coronary artery disease (CAD) undergoing LT have higher morbidity and mortality rates compared to recipients without CAD[ 21 , 22 ]. The incidence of CAD in LT candidates varies widely, ranging 2%-38% depending on the etiology of ESLD, investigation modality used for diagnosis, criteria for significant CAD used in different studies (defined as either ≥ 50% diameter stenosis of ≥ 1 major epicardial vessels vs ≥ 70% stenosis), and heterogeneity of the surveyed populations[ 4 , 10 , 21 , 23 ]. Among ESLD patients without symptoms of CAD, prevalence of obstructive CAD (defined as ≥ 50% diameter stenosis of ≥ 1 major epicardial vessels) is similar to that of the general population[ 24 ].…”

“…Besides the well-established implications of obstructive CAD, nonobstructive CAD plays an important role in LT candidates. Patients with ESLD have a significantly higher prevalence of silent nonobstructive CAD in comparison with matched subjects without liver disease[ 21 , 24 ]. This is relevant as any degree of CAD, obstructive or non-obstructive, has been associated with a significantly higher risk of major adverse cardiac events (MACE) after transplant[ 21 , 24 , 25 ].…”

“…Patients with ESLD have a significantly higher prevalence of silent nonobstructive CAD in comparison with matched subjects without liver disease[ 21 , 24 ]. This is relevant as any degree of CAD, obstructive or non-obstructive, has been associated with a significantly higher risk of major adverse cardiac events (MACE) after transplant[ 21 , 24 , 25 ]. Additionally, the prevalence of CAD in ESLD from NASH/cryptogenic etiology is higher compared to other etiologies of ESLD and parallels the increased risk of postoperative myocardial ischemia in this subset of transplant recipients[ 4 ].…”