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.
Keywords: ACS, Acute coronary syndromes; ALD, alcoholic liver disease; ASCVD, Atherosclerotic cardiovascular disease; ASCVD, atherosclerosis cardiovascular disease risk; BMI, Body mass index; CABG, Coronary angioplasty bypass surgery; CAC, Coronary calcium score; CAD, Coronary artery disease; CKD, chronic kidney disease; DSE/SPECT, Dobutamine stress echocardiogram or single-photon emission computed tomography; ESLD, End-stage liver disease; HCV, hepatitis C virus; IQR, Interquartile range; LCx, left circumflex; LHC, Left heart catheterization; LT, liver transplantation; MELD, model for end stage liver disease; MESA, Multi-Ethnic Study of Atherosclerosis; METs, Metabolic equivalents; NPV, negative predictive value; OM, obtuse marginal; OPTN, Organ Procurement and Transplantation Network; PCI, Percutaneous coronary intervention; PDA, posterior descending artery; POBA, plain old balloon angioplasty; PPV, positive predictive value; RCA, right coronary artery; RI, ramus intermedius; ROC, Receiver operating characteristic; RPL, right posterolateral; SD, Standard deviation; VT, Ventricular tachycardia; agatston score; angiogram; cardiac stress test; cirrhosis; end-stage liver disease.
© 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.