Cardiac involvement in patients with cirrhosis: a focus on clinical features and diagnosis

Electrocardiographic characteristics of cirrhotic patients and their association with Child-Pugh score

BACKGROUND

Cardiac dysfunction is a serious complication of cirrhosis which is usually asymptomatic. We investigated the clinical and electrocardiographic (ECG)-related factors among patients with cirrhosis and our aim was to find any associations between ECG changes and the etiology of cirrhosis, as well as Child-Pugh score.

HYPOTHESIS

We hypothesized that some ECG-related factors, particularly prolonged QT interval, are more common in patients with cirrhosis. Also, these factors are associated with the severity of cirrhosis, measured by the Child-Pugh score.

METHODS

From April 2019 to December 2022, we reviewed admitted patients to Namazi and Abu-Ali Sina hospitals, Shiraz, Iran. Patients with confirmed diagnosis of cirrhosis and without concurrent disorders affecting the cardiovascular system were selected. Clinical and ECG-related data were then extracted for participants, and Child-Pugh score was calculated.

RESULTS

A total of 425 patients were included; the median age was 36 years, and 245 patients (57.6%) were men. Cryptogenic and primary sclerosing cholangitis were the most common etiologies. Prolonged QT followed by early transitional zone were the most common ECG changes (24.7% and 19.8%, respectively), which were significantly associated with the etiology of cirrhosis and Child-Pugh class.

CONCLUSIONS

Prolonged QT interval and presence of early transitional zone in patients with cirrhosis may indicate cardiac dysfunction, necessitating further evaluations.

Part 1: Disease of the Heart and Liver: A Relationship That Cuts Both Ways

The heart and the liver display multifaceted, complex interactions that can be divided into cardiac effects of liver disease, hepatic effects of heart disease, and disease processes affecting both organs. In part 1 of this 2 part series, we discuss how acute and chronic heart failure can have devastating effects on the liver, such as acute cardiogenic liver injury and congestive hepatopathy. On the other hand, primary liver disease, such as cirrhosis, can lead to a plethora of cardiac insults representative in cirrhotic cardiomyopathy as systolic dysfunction, diastolic dysfunction, and electrophysiological disturbances. Nonalcoholic fatty liver disease has long been associated with cardiovascular events that increase mortality. The management of both disease processes changes when the other organ system becomes involved. This consideration is important with regard to a variety of interventions, most notably transplantation of either organ, as risk of complications dramatically rises in the setting of both heart and liver disease (discussed in part 2). As our understanding of the intricate communication between the heart and liver continues to expand so does our management.

Cirrhotic Cardiomyopathy - A Veiled Threat

Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.

Relationship between Heart Disease and Liver Disease: A Two-Way Street

In clinical practice, combined heart and liver dysfunctions coexist in the setting of the main heart and liver diseases because of complex cardiohepatic interactions. It is becoming increasingly crucial to identify these interactions between heart and liver in order to ensure an effective management of patients with heart or liver disease to provide an improvement in overall prognosis and therapy. In this review, we aim to summarize the cross-talk between heart and liver in the setting of the main pathologic conditions affecting these organs. Accordingly, we present the clinical manifestation, biochemical profiles, and histological findings of cardiogenic ischemic hepatitis and congestive hepatopathy due to acute and chronic heart failure, respectively. In addition, we discuss the main features of cardiac dysfunction in the setting of liver cirrhosis, nonalcoholic fatty liver disease, and those following liver transplantation.

Cirrhotic cardiomyopathy: the liver affects the heart

Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.

Subclinical cardiovascular damage in patients with HCV cirrhosis before and after treatment with direct antiviral agents: a prospective study

BACKGROUND

Cirrhosis is associated with morpho-functional cardiovascular alterations.

AIMS

To detect early features of cardiovascular damage in HCV-compensated cirrhotic patients using myocardial deformation indices and carotid arterial stiffness, and, further, to evaluate their short-term behaviour after HCV eradication with direct antiviral agents (DAAs).

METHODS

Thirty-nine consecutive patients with HCV cirrhosis, without previous cardiovascular events, were studied and matched for age, gender and cardiovascular risk factors to 39 controls without liver or cardiovascular disease. Patients and controls underwent a baseline echocardiographic evaluation including global longitudinal strain and ultrasound scan of carotid arteries. HCV-cirrhotics were reassessed by echocardiography and carotid ultrasound after obtaining sustained virological response (SVR) on DAAs.

RESULTS

HCV-cirrhotics showed at baseline a significantly reduced global longitudinal strain compared to controls -18.1 (16.3-20.5) vs -21.2 (20.4-22.3), P < 0.001. They also had a significantly higher pulse wave velocity 8.6 (7.7-9.1) m/s vs 6.6 (6.0-7.1) m/s, P = 0.0001, and β-stiffness index 12.4 (11.1-13.5) vs 8.6 (8.0-9.2) P = 0.0001. At multiple regression analysis, diabetes and HCV cirrhosis were independent predictors of global longitudinal strain. All HCV-cirrhotic patients had SVR on DAAs. Follow-up available in 32 of 39 (82%) at 9 (8-10) months showed a significant improvement of tricuspid annular plane systolic excursion (P = 0.01) and lateral E' velocity compared to baseline (P = 0.001).

CONCLUSIONS

HCV-cirrhotics show a significant rate of subclinical cardiac and vascular abnormalities. At a time when their survival is less linked to progression of liver disease, due to viral eradication on DAAs, cardiovascular morbidity and mortality may take a significant role.

Cirrhotic cardiomyopathy: Basic and clinical research

Cirrhotic cardiomyopathy (CCM) is a common complication of liver cirrhosis. Recent research found that a blunted inotropic and chronotropic response to stress, systolic and diastolic dysfunctions and prolongation of the QT interval are major reasons for the development of cardiovascular events under stress conditions in CCM patients. Myocardial apoptosis, abnormalities of adrenergic transduction pathways, gaseous signal molecule imbalance and derangement of various ion channels are involved in the development of CCM. The combination of measurement of BNP, H₂S, electrocardiogram and echocardiography (resting and stress) is' helpful in the diagnosis of CCM. Liver transplantation is the only proven treatment with specific effect on CCM. Monitoring of cardiac function and timely treatment in case of severe trauma and infection are effective measures for preventing cardiovascular events. Only aldosterone antagonists have certain effects on CCM. The clinical efficacy of TCM therapy needs to be verified in future studies. New agents, targeting its pathogenic mechanisms, such as supplementing exogenous hydrogen sulfide, may play a role in patients who cannot undergo liver transplantation.