Cirrhotic cardiomyopathy among patients with liver cirrhosis

Tilahun Belay, Todd Gress, Rameez Sayyed

Department of Cardiovascular Medicine, Marshall University, Huntington, USA.
Department of Internal Medicine, Marshall University, Huntington, USA.

DOI: 10.4236/ojgas.2013.38060                

Abstract

Introduction: Cirrhotic cardiomyopathy (CCM) is a clinical syndrome in patients with liver cirrhosis characterized by an abnormal and blunted response in cardiac output and contractility to physiologic, pathologic, or pharmacologic stress but a normal to increased cardiac response at rest [1-4]. Information on the epidemiology and natural history of CCM is limited. Methods: All patients with a diagnosis of cirrhosis (N = 451) seen at gastroenterology clinic over the four years were evaluated. CCM was defined using echocardiogram (ECHO) and electrocardiogram (ECG) criteria [1]. Patients with structural or ischemic heart disease or incomplete information were excluded (N = 220). Results: Among the 231 patients with cirrhosis, 118 (51.1%) met criteria for CCM, and no patient had this problem documented in their medical record. Those with CCM were older (62.7 vs 57.8 years; p < 0.001) and more likely to be female (55.8 vs 40.2%; p = 0.02) compared to those without CCM. The likelihood of CCM increased with each quartile of age (OR 1.6 per quartile; 95% CI 1.2-2.0). Patients with alcoholic and unknown causes of cirrhosis are more likely to have CCM, (p < 0.001). CCM was more commonly associated with alcohol abuse in men than women (49.1 vs 21.3%; p = 0.002). Conclusion: CCM, a diagnosis of exclusion, defined by ECHO and ECG criteria is a common problem among cirrhotic patients attending a gastroenterology practice. Advancing age and female gender were associated with a higher prevalence of CCM, but the cause of cirrhosis was not possibly limited by smaller sample size within cause-specific categories. CCM was not recognized by our clinicians, and routine screening tests were not performed. Provider awareness of CCM is needed since implementation of angiotensin receptor blocker and beta-blocker therapy early in the course of cirrhosis may modify the changes in cardiac function [5,6].

 

Keywords

Cirrhosis; Cardiomyopathy

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Zardi, E.M., et al. (2010) Cirrhotic cardiomyopathy. Journal of the American College of Cardiology, 56, 539-549. http://dx.doi.org/10.1016/j.jacc.2009.12.075
[2]	Al Hamoudi, W. and Lee, S.S. (2006) Cirrhotic cardiomyopathy. Annals of Hepatology, 5, 132-139.
[3]	Baik, S.K., Fouad, T.R. and Lee, S.S. (2007) Cirrhotic cardiomyopathy. Orphanet Journal of Rare Diseases, 2, 15. http://dx.doi.org/10.1186/1750-1172-2-15
[4]	Christos, A., Fourlas, C.A. and Alexopoulou, A.A. (2004) Cirrhotic cardiomyopathy. Hellenic Journal of Cardiology, 45, 114-120.
[5]	Liu, H., Song, D. and Lee, S.S. (2002) Cirrhotic cardiomyopathy. Gastroentérologie Clinique et Biologique, 26, 842-847.
[6]	Henriksen, J.H., Bendtsen, F., Hansen, E.F. and Moller, S. (2004) Acute non-selective beta-adrenergic blockade reduces prolonged frequency-adjusted Q-T interval (QTc) in patients with cirrhosis. Journal of Hepatology, 40, 239-246. http://dx.doi.org/10.1016/j.jhep.2003.10.026
[7]	Grose, R.D., Noan, J., Dillon, J.F., Errington, M., et al. (1995) Exercise induced let ventricular dysfunction in alcoholic and non alcoholic cirrhosis. Journal of Hepatology, 22, 326-332. http://dx.doi.org/10.1016/0168-8278(95)80286-X
[8]	Wong, F., et al. (2001) The cardiac response to exercise in cirrhosis. Gut, 49, 268-275. http://dx.doi.org/10.1136/gut.49.2.268
[9]	Murray, J.G., Dawson, A.M. and Sherlock, S. (1958) Circulatory changes in chronic liver disease. American Journal of Medicine, 24, 358-367. http://dx.doi.org/10.1016/0002-9343(58)90322-X
[10]	Ma, Z. and Lee, S.S. (1996) Cirrhotic cardiomyopathy: Getting to the heart of the matter. Hepatology, 24, 451-459. http://dx.doi.org/10.1002/hep.510240226
[11]	Liu, H. and Lee, S.S. (1999) Cardiopulmonary dysfunction in cirrhosis. Journal of Gastroenterology and Hepatology, 14, 600-608. http://dx.doi.org/10.1046/j.1440-1746.1999.01920.x
[12]	Grose, R.D., et al. (1995) Exercise-induced left ventricular dysfunction in alcoholic and non-alcoholic cirrhosis. Journal of Hepatology, 22, 326-332. http://dx.doi.org/10.1016/0168-8278(95)80286-X
[13]	Finucci, G., et al. (1996) Left ventricular diastolic function in liver cirrhosis. Scandinavian Journal of Gastroenterology, 31, 279-284. http://dx.doi.org/10.3109/00365529609004879
[14]	Pozzi, M., et al. (1997) Evidence of functional and structural cardiac abnormalities in cirrhotic patients with and without ascites. Hepatology, 26, 1131-1137.
[15]	Wong, F., Liu, P., Lilly, L., Bomzon, A. and Blendis, L. (1999) Role of cardiac structural and functional abnormalities in the pathogenesis of hyperdynamic circulation and renal sodium retention in cirrhosis. Clinical Science (London), 97, 259-267. http://dx.doi.org/10.1042/CS19990026
[16]	Wong, F., et al. (2001) The cardiac response to exercise in cirrhosis. Gut, 49, 268-275. http://dx.doi.org/10.1136/gut.49.2.268
[17]	Abelmann, W.H., Kowalski, H.J. and McNeely, W.F. (1955) The hemodynamic response to exercise in patients with laennec’s cirrhosis. Journal of Clinical Investigation, 34, 690-695. http://dx.doi.org/10.1172/JCI103120
[18]	Kim, M.Y. and Baik, S.K. (2007) Cirrhotic cardiomyopathy. Korean Journal of Hepatology, 13, 22-26.
[19]	Liu, H.Q., Gaskari, S.A. and Lee, S.S. (2006) Cardiac and vascular changes in cirrhosis: Pathogenic mechanisms. World Journal of Gastroenterology, 12, 837-842.
[20]	Donovan, C.L., et al. (1996) Two dimensional and dobutamine stress echocardiography in the prospective assessment of patients with end stage liver disease prior to orthotopic liver transplantation. Transplantation, 61, 1180-1188. http://dx.doi.org/10.1097/00007890-199604270-00011
[21]	Myers, R.P. and Lee, S.S. (2000) Cirrhotic cardiomyopathy and liver transplantation. Liver Transplantation, 6, S44-S52. http://dx.doi.org/10.1002/lt.500060510
[22]	Kempler, P., et al. (1993) Prolongation of the QTc-interval reflects the severity of autonomic neuropathy in primary biliary cirrhosis and in other non-alcoholic liver diseases. Zeitschrift für Gastroenterologie, 31, 96-98.
[23]	Bernardi, M., et al. (1998) Q-T interval prolongation in cirrhosis: Prevalence, relationship with severity and etiology of the disease and possible pathogenetic factors. Hepatology, 27, 28-34. http://dx.doi.org/10.1002/hep.510270106
[24]	Finucci, G., et al. (1998) Q-T interval prolongation in liver cirrhosis. Reversibility after orthotopic liver transplantation. Japanese Heart Journal, 39, 321-329. http://dx.doi.org/10.1536/ihj.39.321
[25]	Blendis, L. and Wong, F. (2000) Is there a cirrhotic cardiomyopathy? American Journal of Gastroenterology, 95, 3026-3028. http://dx.doi.org/10.1111/j.1572-0241.2000.03249.x
[26]	Navasa, M., et al. (1993) Hemodynamic and humoral changes after liver transplantation in patients with cirrhosis. Hepatology, 17, 355-360. http://dx.doi.org/10.1002/hep.1840170302
[27]	Henriksen, J.H., Bendtsen, F., Hansen, E.F. and Moller, S. (2004) Acute non-selective beta-adrenergic blockade reduces prolonged frequency-adjusted Q-T interval (QTc) in patients with cirrhosis. Journal of Hepatology, 40, 239-246. http://dx.doi.org/10.1016/j.jhep.2003.10.026
[28]	Gould, L., Shariff, M., Zahir, M. and Di Lieto, M. (1969) Cardiac haemodynamics in alcoholic patients with chronic liver disease and presystolic gallop. Journal of Clinical Investigation, 48, 860-868. http://dx.doi.org/10.1172/JCI106044
[29]	Hendrickse, M.T. and Triger, D.R. (1994) Vagal dysfunction and impaired urinary sodium and water excretion in cirrhosis. American Journal of Gastroenterology, 89, 750-757.
[30]	Hansen, S., Moller, S., Bendtsen, F., Jensen, G. and Henriksen, J.H. (2007) Diurnal variation and dispersion in QT interval in cirrhosis: Relation to haemodynamic changes. Journal of Hepatology, 47, 373-380. http://dx.doi.org/10.1016/j.jhep.2007.03.013
[31]	Moller, S., et al. (2012) New insights into cirrhotic cardiomyopathy. International Journal of Cardiology, 167, 1101-1108.
[32]	Moller, S. and Henriksen, J.H. (2009) Cardiovascular complications of cirrhosis. Postgraduate Medical Journal, 85, 44-54.