Liver stiffness and arterial stiffness/abnormal central hemodynamics in the early stage of heart failure

Liver fibrosis and outcomes of atrial fibrillation: the FIB-4 index

BACKGROUND AND AIMS

Liver diseases play an important role in the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB-4) index is a non-invasive score recommended for detecting liver fibrosis. Since the association between liver fibrosis and outcomes of AF patients is still not well defined, we aim to analyze prognosis impact of FIB-4 index in those patients.

METHODS

A retrospective population-based cohort study was performed with 12,870 unselected patients from a single health area in Spain with AF from 2014 to 2019. Cox regression models were used to estimate the association of FIB-4 index with mortality. The association with ischemic stroke (IS), major bleeding (MB), acute myocardial infarction (AMI), and heart failure (HF) was assessed by competing risk analysis.

RESULTS

A total of 61.1%, 22.0%, and 16.9% were classified as low, moderate and high risk of liver fibrosis according to FIB-4 index, respectively. During a mean follow-up of 4.5 ± 1.7 years, FIB-4 index was associated with mortality (adjusted HR 1.04; 95% CI 1.01-1.06; p = 0.002), MB and HF (adjusted sHR 1.03, 95% CI 1.01-1.04; p = 0.004), but not with IS or with AMI. The association between FIB-4 and MB was only found in patients treated with vitamin K antagonists, not in patients on direct oral anticoagulants.

CONCLUSIONS

The FIB-4 index, a non-invasive scoring method for evaluating liver fibrosis, is independently associated with all-cause mortality, MB and HF in patients with AF, suggesting that it may be useful as a risk assessment tool to identify adverse outcomes in patients with AF.

Association between Cardiovascular Disease and Liver Disease, from a Clinically Pragmatic Perspective as a Cardiologist

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.

The fibrosis-4 score is associated with long-term mortality in different phenotypes of acute heart failure

BACKGROUND

Fibrosis-4 score (FIB4) was a non-invasive surrogate to estimate the amount of liver scarring in chronic hepatitis. Considering the presence of increased central venous pressure and congestive hepatopathy in patients with decompensated heart failure, we therefore investigated the prognostic values of FIB4 in acute heart failure (AHF) patients.

METHOD

Patients hospitalised primarily for HF were drawn from an intramural registry. FIB4 was calculated according to age, aspartate aminotransferase, alanine aminotransferase and platelet count. All-cause mortality up to 5 years after discharge was obtained by linking to the national death registry.

RESULTS

Among a total of 1854 participants, 940 patients died during a mean follow-up of 28.3 ± 21.8 months. FIB4 score was related to mortality and the composite of cardiovascular death or HF rehospitalisation, independent of age, sex, left ventricular ejection fraction, left atrial dimension, sodium and haemoglobin levels, estimated glomerular filtration rate, comorbidities, and medications [hazard ratio and 95% confidence interval of mortality: 1.009 (1.002-1.015), and the composite of cardiovascular death or HF hospitalisation: 1.020 (1.010-1.031)]. The prognostic value of FIB4 was predominantly in the subjects with heart failure and preserved or mildly reduced ejection fraction (HFpEF and HFmrEF), or coronary artery disease (CAD) than the counterparts [interaction p-value <0.001, and 0.004, respectively].

CONCLUSIONS

FIB4 was an independent predictor of survival in AHF patients, irrespective of the phenotypes of HF. The higher predictive value of mortality of FIB4 was observed in the subjects with HFpEF, HFmrEF or CAD.

Fibrosis-4 index reflects right ventricular function and prognosis in heart failure with preserved ejection fraction

Aims

Fibrosis‐4 index (FIB‐4 index), calculated by age, aspartate aminotransferase, alanine aminotransferase, and platelet count, is a simple marker to evaluate liver fibrosis and is associated with right‐sided heart failure. However, the clinical relevance of FIB‐4 in patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. We investigated the prognostic implication of the FIB‐4 index regarding right ventricular dysfunction in patients with HFpEF.

Methods and results

This prospective study included 116 consecutive HFpEF patients (mean age 79 years, 43% male) hospitalized with acute decompensated heart failure. We evaluated the association of the FIB‐4 index with right ventricular function determined by tricuspid annular plane systolic excursion (TAPSE) and tricuspid lateral annular systolic velocity (S′) before discharge. Cox regression analysis was performed to evaluate the association between the FIB‐4 index and major adverse cardiovascular events (MACE) defined as the composite of cardiovascular death, readmission for heart failure, nonfatal myocardial infarction, and nonfatal stroke. FIB‐4 index before discharge was significantly lower than that at admission (2.62 [1.92–3.46] and 3.03 [2.05–4.67], median [interquartile range], P < 0.001). Left ventricular ejection fraction, TAPSE, and S′ before discharge were 62.7 (55.9–68.6) %, 17.5 ± 4.6 mm (mean ± standard deviation), and 10.0 (8.0–12.0) cm/s, respectively. In multiple linear regression analysis, the FIB‐4 index before discharge was inversely correlated with TAPSE (β minus;0.244, P = 0.014) and S′ (β −0.266, P = 0.009). During a median follow‐up of 736 days, 37 MACE occurred. Multivariate Cox regression analysis revealed that a high FIB‐4 index before discharge (per 1 point) was a significant predictor of MACE (hazard ratio 1.270, 95% confidence interval 1.052–1.532) after adjustment for male, serum creatinine, and haemoglobin. Receiver operating characteristic analysis indicated that the optimal cut‐off value of FIB‐4 index before discharge to predict MACE was 3.11. Kaplan–Meier survival analysis showed that patients with a FIB‐4 index before discharge ≥3.11 had a significantly poorer prognosis than patients with FIB‐4 index before discharge <3.11 (P = 0.029). Patients with an FIB‐4 index ≥3.11 had a 2.202‐fold (95% confidence interval 1.110–4.368) increased risk of MACE compared with those with an FIB‐4 index <3.11 after adjustment for male, serum creatinine, and haemoglobin.

Conclusions

An increase in the FIB‐4 index was associated with right ventricular dysfunction and a higher risk of future MACE in patients with HFpEF.

Liver Congestion Assessed by Hepatic Vein Waveforms in Patients With Heart Failure

Background

It has been reported that the pattern of hepatic vein (HV) waveforms determined by abdominal ultrasonography is useful for the diagnosis of hepatic fibrosis in patients with chronic liver disease. We aim to clarify the clinical implications of HV waveform patterns in patients with heart failure (HF).

Methods

We measured HV waveforms in 350 HF patients, who were then classified into 3 categories based on their waveforms: those with a continuous pattern (C group); those whose V wave ran under the baseline (U group), and those with a reversed V wave (R group). We performed right-heart catheterization, and examined the rate of postdischarge cardiac events, such as cardiac death and rehospitalization due to worsening HF.

Results

The number of patients in each of the 3 HV waveform groups was as follows: C group, n = 158; U group, n = 152, and R group, n = 40. The levels of B-type natriuretic peptide (R vs C and U; 245.8 vs 111.7 and 216.6 pg/mL; P < 0.01) and mean right atrial pressure (10.5 vs 6.7 and 7.2 mm Hg; P < 0.01) were highest in the R group compared with the other groups. The Kaplan-Meier analysis found that cardiac event–free rates were lowest in the R group among all groups (log-rank P < 0.001). In the multivariable Cox proportional hazard analysis, the R group was found to be an independent predictor of cardiac events (hazard ratio, 4.90; 95% confidence interval, 2.23-10.74; P < 0.01).

Conclusion

Among HF patients, those with reversed V waves had higher right atrial pressure and were at higher risk of adverse prognosis.

Prognostic value of impaired hepato-renal function and liver fibrosis in patients admitted for acute heart failure

AIMS

Cardiohepatic interactions have been a focus of attention in heart failure (HF). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score has been shown to be useful for predicting poor outcomes in patients with acute decompensated HF (ADHF). Furthermore, the fibrosis-4 (FIB-4) index, a simple marker to assess liver fibrosis, predicts adverse prognoses in patients with HF as well. However, there is little information available on the prognostic significance of the combination of the MELD-XI score and FIB-4 index in patients with ADHF and its association with left ventricular ejection fraction (LVEF) subgroup.

METHODS AND RESULTS

We prospectively studied 466 consecutive patients who were admitted for ADHF [HF with reduced LVEF (LVEF < 40%): n = 164, HF with mid-range LVEF (40% ≤ LVEF < 50%): n = 104, and HF with preserved LVEF (LVEF ≥ 50%): n = 198]. We calculated the MELD-XI score and FIB-4 indices at discharge. The primary endpoint was all-cause death (ACD). During the mean follow-up period of 2.8 years, 143 patients had ACD. In the multivariate Cox analysis, the MELD-XI score and FIB-4 index were independently associated with ACD. Patients were stratified into the following three groups according to the median value of MELD-XI score (=11) and FIB-4 index (=2.13): Group 1 had both a low MELD-XI score and a low FIB-4 index; Group 2 had either a high MELD-XI score (MELD-XI score ≥11) or a high FIB-4 index (FIB-4 index ≥2.13); and Group 3 had both a high MELD-XI score and a high FIB-4 index. Kaplan-Meier analysis revealed that Group 2 and Group 3 had a significantly greater risk of ACD than Group 1 [Group 2 vs. Group 1: adjusted hazard ratio, 2.48 (95% confidence interval: 1.75-3.53), P < 0.0001; Group 3 vs. Group 1: adjusted hazard ratio, 7.03 (95% confidence interval: 3.95-13.7), P < 0.0001]. In addition, the patients with both a higher MELD-XI score and FIB-4 index showed a significantly higher risk of ACD also in the patients with HF with reduced LVEF, HF with mid-range LVEF, and HF with preserved LVEF (all P < 0.0001).

CONCLUSIONS

The combination of MELD-XI score and FIB-4 index may be useful for stratifying patients at risk for ACD in patients with ADHF, irrespective of LVEF.

Correlation of the Fatty Liver Index with the Pathophysiological Abnormalities Associated with Cardiovascular Risk Markers in Japanese Men without any History of Cardiovascular Disease: Comparison with the Fibrosis-4 Score

Aim: Fatty liver and the liver fibrosis are known risk factors for cardiovascular disease (CVD). The severity of fatty liver can be assessed by determining the fatty liver index (FLI), and the severity of liver fibrosis can be assessed by determining the fibrosis-4 (FIB-4) score. We examined the differences in the associations of these two liver scoring systems with the pathophysiological abnormalities associated with the risk of development of CVD.

Methods: The FLI and FIB-4 score were calculated in 2,437 Japanese men without any history of CVD. The serum NT-pro-BNP levels and brachial-ankle pulse wave velocity (baPWV) were also measured at the start of the study and the end of three years’ follow-up.

Results: The FLI was significantly correlated with the baPWV ( p ＜0.01) and the FIB-4 score was significantly correlated with the serum NT-pro-BNP level ( p ＜0.01). Furthermore, the delta change of the FLI was significantly correlated with the delta change of the baPWV during the study period ( p =0.01), and the delta change of the FIB-4 score was significantly correlated with the delta change of the serum NT-pro-BNP level during the study period ( p ＜0.01).

Conclusions: While the FIB-4 score may serve as a marker of the risk of development of heart failure, the FLI may be a marker of arterial stiffness in Japanese men without any history of CVD.

Hepatic Fibrosis Assessed Using Fibrosis-4 Index Is Predictive of All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Various comorbidities influence the prognosis of patients with chronic obstructive pulmonary disease (COPD). We investigated if liver fibrosis assessed using fibrosis-4 index (FIB-4) is associated with all-cause mortality in patients with COPD.

METHODS

We included 756 patients diagnosed with COPD between 2006 and 2010. Medical records were retrospectively reviewed until 2018. FIB-4 was calculated using the following equation: [age (years) × aspartate aminotransferase (IU/L)/(platelet count (109/L) × √alanine aminotransferase (IU/L))].

RESULTS

From a total of 756 patients, 582 (76.9%) patients were categorized into survivor and 174 (23.1%) into non-survivor groups. The non-survivor group was significantly older with a higher proportion of male, smoker and lower FEV1/FVC ratio than the survivor group (all P<0.05). Various comorbidities were more frequently observed in the non-survivor group (P<0.05). In addition, the non-survivor group had significantly higher FIB-4 than the survivor group (1.8 vs 1.4, P<0.001). In multivariate analysis, older age (hazard ratio [HR]=1.05), underlying malignancy (HR=2.94), coronary artery occlusive disease (HR=1.58), higher FIB-4 (HR=1.15), and higher GOLD stage (HR=1.26) were significantly associated with the increased risk of all-cause mortality (P<0.05), whereas body mass index (HR=0.95) was independently protective for all-cause mortality (all P<0.05). The high FIB-4 (>1.57) group showed a significantly lower cumulative survival rate than the low FIB-4 (≤1.05) group (P=0.031, Log-rank test). In multivariate regression analysis, higher FIB-4 independently predicted the risk of acute exacerbation (odds ratio=1.08, P=0.034).

CONCLUSION

Higher fibrotic burden assessed using FIB-4 was independently predictive of the increased risk of all-cause mortality and acute exacerbation in patients with COPD.

Possible Mechanisms Underlying Elevated Serum N-Terminal Pro-Brain Natriuretic Peptide in Healthy Japanese Subjects

Background: The precise mechanisms underlying elevation of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) in healthy subjects have not been fully clarified.

Methods and Results: In 2,844 Japanese healthy subjects with serum NT-proBNP <125 pg/mL, (1) brachial-ankle pulse wave velocity and (2) second peak of the peripheral systolic blood pressure minus diastolic blood pressure (pulse pressure 2 [PP2]), as markers of cardiac afterload; (3) fibrosis 4 score (FIB-4 score, a marker of liver fibrosis), as a marker of cardiac preload; and (4) ratio of the pre-ejection time to ejection time (PEP/ET), as a marker of cardiac systolic function, were measured. At the first examination, after the adjustments, log-transformed serum NT-proBNP was associated with PP2 and FIB-4 score, but not with PEP/ET. These parameters were successfully measured again after a 3-year interval in 1,978 subjects. On Pearson’s correlation analysis, change in PP2 and FIB-4 score during the study period was significantly correlated with change in serum NT-proBNP (r=0.05, 0.09, respectively; P<0.01).

Conclusions: In apparently healthy Japanese subjects, both increased cardiac preload and increased cardiac afterload, but not impaired cardiac systolic function, may be associated with elevated serum NT-proBNP.