Journal
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Volume 12, Issue 2, Pages 319-328Publisher
ELSEVIER - DIVISION REED ELSEVIER INDIA PVT LTD
DOI: 10.1016/j.jceh.2021.08.015
Keywords
agatston score; cardiac stress test; angiogram; cirrhosis; end-stage liver disease
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Funding
- University of Arkansas for Medical Sciences College of Medicine Clinician Scientist Program, Little Rock, Arkansas, USA
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This study found that coronary artery calcium score (CAC) is a promising tool to guide coronary artery disease (CAD) risk stratification and the need for left heart catheterization (LHC) during liver transplantation (LT) evaluation. Patients with CAC < 100 can safely undergo LT without the need for LHC or cardiac stress testing, whereas a CAC < 346 accurately rules out significant CAD stenosis (>= 70%) on LHC, outperforming other CAD risk-stratification strategies.
Background: End-stage liver disease (ESLD) is not considered a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, lifestyle characteristics commonly associated with increased ASCVD risk are highly prevalent in ESLD. Emerging literature shows a high burden of asymptomatic coronary artery disease (CAD) in patients with ESLD and a high ASCVD risk in liver transplantation (LT) recipients. Coronary artery calcium score (CAC) is a noninvasive test providing reliable CAD risk stratification. We implemented an LT evaluation protocol with CAC playing a central role in triaging and determining the need for further CAD assessment. Here, we inform our results from this early experience. Methods: Patients with ESLD referred for LT evaluation were prospectively studied. We compared accuracy of CAC against that of CAD risk factors/scores, troponin I, dobutamine stress echocardiogram (DSE), and single-photon emission computed tomography (SPECT) to detect coronary stenosis >= 70 (CAD >= 70) per left heart catheterization (LHC). Thirty-day post-LT cardiac outcomes were also analyzed. Results: One hundred twenty-four of 148 (84%) patients underwent CAC, 106 (72%) DSE/SPECT, and 50 (34%) LHC. CAC >= 400 was found in 35 (28%), 100 to 399 in 17 (14%), and <100 in 72 (58%). LHC identified CAD >= 70% in 8 of 29 (28%), 2 of 9 (22%), and 0 of 4, respectively. Two acute coronary syndromes occurred after LT in a patient with CAC 811 (CAD < 70%), and one with CAC 347 (CAD >= 70%). No patients with CAC < 100 presented with acute coronary syndrome after LT. When using CAD >= 70% as primary endpoint of LT evaluation, CAC >= 346 was the only test showing predictive usefulness (negative predictive value 100%). Conclusions: CAC is a promising tool to guide CAD risk stratification and need for LHC during LT evaluation. Patients with a CAC < 100 can safely undergo LT without the need for LHC or cardiac stress testing, whereas a CAC < 346 accurately rules out significant CAD stenosis (>= 70%) on LHC, outperforming other CAD risk-stratification strategies.
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