Madhumita Premkumar1, Devaraja Devurgowda1, Tanmay Vyas1, Saggere M Shasthry1, Jelen S Khumuckham2, Ritu Goyal3, Sherin S Thomas3, Guresh Kumar4. 1. Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. 2. Department of Cardiology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. 3. Department of Biochemistry, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. 4. Department of Biostatistics, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India.
Abstract
BACKGROUND: The presence of left ventricular diastolic dysfunction (LVDD) in patients with cirrhosis leads to a restriction of activities and a poor health related quality of life (HRQoL), which should be taken into consideration when treating them for liver and cardiac complications. AIMS: The prevalence, complications, predictors of HRQoL and survival in cirrhotic patients with LVDD were studied. METHODS: We report a prospective cohort study of 145 consecutive cirrhotic patients with LVDD who were evaluated for cardiac functional status at enrollment and followed up for hepatic complications, cardiac events, outcome and HRQoL using the Minnesota Living With Heart Failure Questionnaire (MLHFQ) over a period of 2 years. RESULTS: In total, 145 (mean age 61 years, 59% male) patients were included. Seventeen patients died with 10.5%, 22.5% and 40% mortality rates in patients with Grades 1, 2 and 3 LVDD respectively over 24 months. The parameters that were significant for predicting mortality on bivariate analysis were MELD, MELDNa, hepatic venous pressure gradient, MLHFQ, and left ventricular (LV) diastolic function (e' and E/e' ratio), but only MELD, MELDNa and E/e' remained significant on multivariate analysis. The E/e' ratio (8.7 ± 3.3 in survivors vs. 9.1 ± 2.3 in non-survivors) predicted outcome. On univariate analysis, the predictors of poor HRQoL were the Child-Pugh score ≥9.8 (OR 2.6; 95% confidence intervals (CI) 2.3-9.1, P = 0.041), MELD score ≥ 15.7 (OR 2.48; 95% CI 1.4-3.9, P = 0.029), refractory ascites (OR 1.9; 95% CI 1.1-6.1, P = 0.050), and E/e' ratio ≥7.6 (OR 1.9; 95% CI 1.8-7.1, P = 0.036) The presence of Class II/III (P = 0.046) symptoms of heart failure and MLHFQ≥ 45 (P = 0.042) were predictors of mortality at 24 months. CONCLUSION: The grade of LVDD correlates with liver function, clinical events, risk of renal dysfunction and HRQoL. Evaluation of novel therapies which target symptomatic improvement in LVDD, should be done with suitable outcome measures, including HRQoL assessment.
BACKGROUND: The presence of left ventricular diastolic dysfunction (LVDD) in patients with cirrhosis leads to a restriction of activities and a poor health related quality of life (HRQoL), which should be taken into consideration when treating them for liver and cardiac complications. AIMS: The prevalence, complications, predictors of HRQoL and survival in cirrhotic patients with LVDD were studied. METHODS: We report a prospective cohort study of 145 consecutive cirrhotic patients with LVDD who were evaluated for cardiac functional status at enrollment and followed up for hepatic complications, cardiac events, outcome and HRQoL using the Minnesota Living With Heart Failure Questionnaire (MLHFQ) over a period of 2 years. RESULTS: In total, 145 (mean age 61 years, 59% male) patients were included. Seventeen patients died with 10.5%, 22.5% and 40% mortality rates in patients with Grades 1, 2 and 3 LVDD respectively over 24 months. The parameters that were significant for predicting mortality on bivariate analysis were MELD, MELDNa, hepatic venous pressure gradient, MLHFQ, and left ventricular (LV) diastolic function (e' and E/e' ratio), but only MELD, MELDNa and E/e' remained significant on multivariate analysis. The E/e' ratio (8.7 ± 3.3 in survivors vs. 9.1 ± 2.3 in non-survivors) predicted outcome. On univariate analysis, the predictors of poor HRQoL were the Child-Pugh score ≥9.8 (OR 2.6; 95% confidence intervals (CI) 2.3-9.1, P = 0.041), MELD score ≥ 15.7 (OR 2.48; 95% CI 1.4-3.9, P = 0.029), refractory ascites (OR 1.9; 95% CI 1.1-6.1, P = 0.050), and E/e' ratio ≥7.6 (OR 1.9; 95% CI 1.8-7.1, P = 0.036) The presence of Class II/III (P = 0.046) symptoms of heart failure and MLHFQ≥ 45 (P = 0.042) were predictors of mortality at 24 months. CONCLUSION: The grade of LVDD correlates with liver function, clinical events, risk of renal dysfunction and HRQoL. Evaluation of novel therapies which target symptomatic improvement in LVDD, should be done with suitable outcome measures, including HRQoL assessment.
Entities:
Keywords:
2D, two-dimensional; A, atrial wave-filling peak; ASE, the American Society of Echocardiography; AUC, area under the curve; BNP, brain natriuretic peptide; CI, confidence interval; CO, cardiac output; DT, deceleration time; E, E-wave transmitral peak early filling; E/A, early diastolic mitral inflow velocity/late diastolic; E/e′ ratio, E-wave transmitral/early diastolic mitral annular velocity; FHVP, free hepatic venous pressure; GI, gastrointestinal; HE, hepatic encephalopathy; HR, heart rate; HRS, hepatorenal syndrome; HVPG, hepatic venous pressure gradient; Health related Quality of Life; Heart Failure; IVRT, isovolumetric relaxation time; LT, liver transplantation; LV, left ventricular; LVDD, left ventricular diastolic dysfunction; LVEF, left ventricular ejection fraction; MAP, mean arterial pressure; MELD, Model for End-Stage Liver Disease; MLHFQ, Minnesota Living with Heart Failure questionnaire; OR, Odds Ratio; PAP, pulmonary artery pressure; PCWP, pulmonary capillary wedged pressure; PH, portal hypertension; RAP, right atrial pressure; RR, relative risk; SBP, spontaneous bacterial peritonitis; SD, standard deviation; TDI, tissue Doppler imaging; TIPS, transjugular intrahepatic portosystemic shunt; TTE, transthoracic echocardiography; USG, ultrasonography; WHVP, wedged hepatic venous pressures; cirrhosis; cirrhotic cardiomyopathy; e′, early diastolic mitral annular velocity; left ventricular diastolic dysfunction
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