The relationship between coronary artery disease and cardiovascular events early after liver transplantation

Abstract

Background & Aims: Cardiovascular complications are major contributors to mortality at liver transplantation (LT). However, the impact of coronary artery disease (CAD) on these complications is not well-understood as the literature is limited by non-invasive assessment of CAD, which is suboptimal in patients with cirrhosis. Thus, the current study evaluated cardiovascular events at LT stratified according to the presence and severity of CAD quantified on coronary angiography. ated (N = 348), but analysis was restricted to patients who had coronary angiography prior to LT (N = 283). Protocol coronary angiography was performed in all patients' ages >50 years, history of CAD, abnormal cardiac stress test or risk factors for CAD.The primary outcome was a cardiovascular composite outcome including myocardial infraction (MI), cardiac arrest, stroke, cardiac death, heart failure or arrhythmia occurring within 4 weeks after LT.Results: CAD was present in 92(32.5%) patients and 32(11.3%) had obstructive CAD.During the study period, 72(25.4%) patients met the primary cardiovascular outcome, the most common being arrhythmia (N = 59 or 20.8%). Non-ST elevation MI occurred in 11(3.9%) of patients. A total of 10 deaths (3.5%) occurred, of which 6(2.1%) were attributable to cardiac death. There was no evidence of a relationship between the presence and severity of CAD and composite cardiovascular events. In multiple regression modelling, only diabetes [OR 2.62, 95%CI (1.49, 4.64), P < 0.001] was associated with the likelihood of having a cardiovascular event.Conclusion: Cardiovascular disease mortality is the most important contributor of early mortality after LT but is not related to the severity of CAD. K E Y W O R D S cardiovascular events, cirrhosis, coronary artery disease, liver transplantation 1364 | PATEL ET AL. | INTRODUC TI ONCardiovascular disease (CVD) is an important contributor to morbidity and mortality during and immediately after liver transplantation (LT). 1,2 More importantly, the presence and severity of coronary artery disease (CAD) has been linked to worse outcomes at LT. 2 The gold standard for CAD assessment is coronary angiography, but it is often deferred in many patients with decompensated cirrhosis because of perceived higher risk of complications, thereby introducing a selection bias in the published literature. [3][4][5] This is compounded further by the suboptimal diagnostic performance of non-invasive cardiac testing in patients with cirrhosis because of blunted heart rate response, body habitus, oedema, deconditioning and impaired functional status. [6][7][8] Thus, it is difficult to interpret the findings of the published literature that have evaluated the impact of underlying CAD on CVD events at the time of LT that used non-invasive cardiac assessment. 9,10 Using coronary angiography, a recent study demonstrated higher prevalence of CAD in potential LT waitlist registrants compared to the general population; 11,12 however, because of relatively small sample size, the association between CAD a...

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“…This could be partly related to the fact that these patients were already being managed for CAD prior to LT and may have received more intensive monitoring after LT. The same group showed that diabetes was associated with an increased risk of having a cardiovascular event, and statin use demonstrated a survival benefit in patients who have undergone LT. 90,91 This supports earlier studies demonstrating the association of MetS with CV complications, thus necessitating early identification and aggressive modification of MetS to improve outcomes.…”

“…89 Interestingly, coronary artery disease (CAD) does not seem to confer an increased risk of CVD mortality in transplant patients. 90 Patel et al recently reported that pre-LT CAD presence and severity did not impact survival after LT. This could be partly related to the fact that these patients were already being managed for CAD prior to LT and may have received more intensive monitoring after LT.…”

Assessment of Malnutrition, Sarcopenia and Frailty in Patients with Cirrhosis: Which Tools Should We Use in Clinical Practice?

“…Cirrhotic cardiomyopathy is a common consequence of cirrhosis, affecting about one third of patients [65]. Coronary artery diseases are also frequent comorbidities as cardiovascular risk factors are more prevalent in this population, especially diabetes [66,67].…”

PRO: Cardiac Catheterization Is the Optimal Strategy for Cardiovascular Risk Stratification in This Patient

“…Although studies have demonstrated that the degree of coronary disease on catheterization at the time of transplant does not predict survival, it is notable that all included patients found to have obstructive disease had revascularization performed prior to transplant, thereby altering the natural course of the disease 17,18 . We now have a decade of data demonstrating the 1‐year survival impact of catheterization and associated coronary intervention, underscoring its importance in the risk stratification process 19,20 .…”

“…15,16 Although studies have demonstrated that the degree of coronary disease on catheterization at the time of transplant does not predict survival, it is notable that all included patients found to have obstructive disease had revascularization performed prior to transplant, thereby altering the natural course of the disease. 17,18 We now have a decade of data demonstrating the 1-year survival impact of catheterization and associated coronary intervention, underscoring its importance in the risk stratification process. 19,20 Beyond percutaneous coronary intervention (PCI), catheterization also allows the identification of more subtle evidence of coronary artery disease (CAD), potentially giving more evidence to modify the patient's risk with statin therapy, an intervention that is significantly underused in this population.…”