|
1
|
Miceli G, Calvaruso V, Casuccio A, Pennisi G, Licata M, Pintus C, Basso MG, Velardo M, Daidone M, Amodio E, Petta S, Simone F, Cabibbo G, Di Raimondo D, Craxì A, Pinto A, Tuttolomondo A. Heart rate variability is associated with disease severity and portal hypertension in cirrhosis. Hepatol Commun 2023; 7:e0050. [PMID: 36757394 PMCID: PMC9916116 DOI: 10.1097/hc9.0000000000000050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/22/2022] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Autonomic nervous system activity in cirrhotic portal hypertension is linked to hyperdynamic circulation. Heart rate variability (HRV) is a validated noninvasive method to assess the sympathovagal balance. To investigate the correlation between HRV parameters and degree of portal hypertension, we studied a cohort of patients with cirrhosis accounting for etiology and treatments. PATIENTS AND METHODS In this cross-sectional, observational cohort study, 157 outpatients of both sex with nonalcoholic cirrhosis were assessed by upper gastrointestinal endoscopy to search for esophagogastric varices. Twenty-four-hour electrocardiogram Holter monitoring with 3 HRV parameters measurement [SD of the NN intervals, root mean square successive difference of NN intervals, and SD of the averages of NN intervals (SDANN)] according to time-domain analysis were performed in all patients. Sixteen patients with large esophagogastric varices underwent measurements of the HVPG and assessment of HRV parameters at baseline and after 45 days on carvedilol. RESULTS The liver dysfunction, expressed by Child-Pugh class or MELD score, was directly related to root mean square successive difference of NN intervals and inversely related to SDANN. Presence of ascites was inversely related to SDANN and to SD of the NN intervals. Treatment with carvedilol had an inverse relation with SDANN. Presence and size of esophagogastric varices had an inverse relation to SDANN and SD of the NN intervals. Upon multivariate analysis the associations between SDANN and Child-Pugh class, size of varices and ascites were confirmed. In the subgroup of 16 patients undergoing HVPG measurement, pressure gradient was unrelated to heart rate and HRV parameters. CONCLUSIONS Time-domain HRV parameters in patients with cirrhosis, confirm the autonomic nervous system alteration, and their correlation to the degree of portal hypertension suggesting a role of the ANS in hepatic decompensation.
Collapse
Affiliation(s)
- Giuseppe Miceli
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| | - Vincenza Calvaruso
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Alessandra Casuccio
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Grazia Pennisi
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Massimo Licata
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Chiara Pintus
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| | - Maria G. Basso
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| | - Mariachiara Velardo
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Mario Daidone
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| | - Emanuele Amodio
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Salvatore Petta
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Fabio Simone
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Giuseppe Cabibbo
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Domenico Di Raimondo
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| | - Antonio Craxì
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Antonio Pinto
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
| | - Antonino Tuttolomondo
- Department of Health promotion, Mother and Child Care, Internal Medicine and Medical specialties (ProMISE) University of Palermo, Piazza delle Cliniche, Palermo, Italy
- Internal Medicine and Stroke Care Ward, University Hospital, Policlinico “P. Giaccone,” Palermo, Italy
| |
Collapse
|
|
2
|
Abid N, Mani AR. The mechanistic and prognostic implications of heart rate variability analysis in patients with cirrhosis. Physiol Rep 2022; 10:e15261. [PMID: 35439350 PMCID: PMC9017982 DOI: 10.14814/phy2.15261] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/19/2022] [Accepted: 03/23/2022] [Indexed: 06/14/2023] Open
Abstract
Chronic liver damage leads to scarring of the liver tissue and ultimately a systemic illness known as cirrhosis. Patients with cirrhosis exhibit multi-organ dysfunction and high mortality. Reduced heart rate variability (HRV) is a hallmark of cirrhosis, reflecting a state of defective cardiovascular control and physiological network disruption. Several lines of evidence have revealed that decreased HRV holds prognostic information and can predict survival of patients independent of the severity of liver disease. Thus, the aim of this review is to shed light on the mechanistic and prognostic implications of HRV analysis in patients with cirrhosis. Notably, several studies have extensively highlighted the critical role systemic inflammation elicits in conferring the reduction in patients' HRV. It appears that IL-6 is likely to play a central mechanistic role, whereby its levels also correlate with manifestations, such as autonomic neuropathy and hence the partial uncoupling of the cardiac pacemaker from autonomic control. Reduced HRV has also been reported to be highly correlated with the severity of hepatic encephalopathy, potentially through systemic inflammation affecting specific brain regions, involved in both cognitive function and autonomic regulation. In general, the prognostic ability of HRV analysis holds immense potential in improving survival rates for patients with cirrhosis, as it may indeed be added to current prognostic indicators, to ultimately increase the accuracy of selecting the recipient most in need of liver transplantation. However, a network physiology approach in the future is critical to delineate the exact mechanistic basis by which decreased HRV confers poor prognosis.
Collapse
Affiliation(s)
- Noor‐Ul‐Hoda Abid
- Network Physiology LabDivision of MedicineUCLLondonUK
- Lancaster Medical SchoolLancaster UniversityLancasterUK
| | - Ali R. Mani
- Network Physiology LabDivision of MedicineUCLLondonUK
| |
Collapse
|
|
3
|
Oyelade T, Canciani G, Carbone G, Alqahtani JS, Moore K, Mani AR. Heart rate variability in patients with cirrhosis: a systematic review and meta-analysis. Physiol Meas 2021; 42. [PMID: 33857926 DOI: 10.1088/1361-6579/abf888] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/15/2021] [Indexed: 12/22/2022]
Abstract
Background. Cirrhosis is associated with abnormal autonomic function and regulation of cardiac rhythm. Measurement of heart rate variability (HRV) provides an accurate and non-invasive measurement of autonomic function as well as liver disease severity currently calculated using the MELD, UKELD, or Child-Pugh scores. This review assesses the methods employed for the measurement of HRV, and evaluates the alteration of HRV indices in cirrhosis, as well as their value in prognosis.Method.We undertook a systematic review using Medline, Embase and Pubmed databases in July 2020. Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias of the included studies was assessed by a modified version of the Newcastle-Ottawa Scale. The descriptive studies were analysed and the standardized mean differences of HRV indices were pooled.Results.Of the 247 studies generated from our search, 14 studies were included. One of the 14 studies was excluded from meta-analysis because it reported only the median of HRV indices. The studies included have a low risk of bias and include 583 patients with cirrhosis and 349 healthy controls. The HRV time and frequency domains were significantly lower in cirrhotic patients. Between-studies heterogeneity was high in most of the pooled studies (P < 0.05). Further, HRV indices predict survival independent of the severity of liver disease as assessed by MELD.Conclusion.HRV is decreased in patients with cirrhosis compared with healthy matched controls. HRV correlated with severity of liver disease and independently predicted survival. There was considerable variation in the methods used for HRV analysis, and this impedes interpretation and clinical applicability. Based on the data analysed, the standard deviation of inter-beat intervals (SDNN) and SDNN corrected for basal heart rate (cSDNN) are the most suitable indices for prognosis in patients with cirrhosis.
Collapse
Affiliation(s)
- Tope Oyelade
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
| | | | | | - Jaber S Alqahtani
- Respiratory Medicine, Division of Medicine, University College London, London NW3 2PF, United Kingdom.,Department of Respiratory Care, Prince Sultan Military College of Health Sciences, Dammam, Saudi Arabia
| | - Kevin Moore
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
| | - Ali R Mani
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London NW3 2PF, United Kingdom
| |
Collapse
|
|
4
|
Kapoor N, Mehta V, Singh B, Karna R, Kumar S, Kar P. Prevalence of cirrhotic cardiomyopathy and its relationship with serum pro-brain natriuretic peptide, hepatorenal syndrome, spontaneous bacterial peritonitis, and mortality. Indian J Gastroenterol 2020; 39:481-486. [PMID: 33188455 DOI: 10.1007/s12664-020-01083-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aims at estimating the prevalence of cirrhotic cardiomyopathy in a cohort of cirrhosis patients in northern India using the World Congress of Gastroenterology 2005 criteria and its relationship with grades of cirrhosis, its complications, and all-cause mortality. METHODS This was a prospective study in which 53 cirrhosis patients underwent the 2D color Doppler, and tissue Doppler echocardiography. Echocardiography findings were compared with thirty age- and sex-matched healthy controls. Additionally, serum pro-brain natriuretic peptide (pro-BNP) and troponin-T levels were measured. Patients were followed up for 6 months to look for complications and mortality. RESULT 2D echocardiography findings revealed that diastolic cardiomyopathy with no gross systolic dysfunction was significantly prevalent in cirrhosis patients. Using the Montreal criteria, we found the incidence of diastolic cardiomyopathy to be 56.6%. Tissue Doppler echocardiography findings were also correlated. Diastolic dysfunction correlated with the severity of cirrhosis, and patients with higher Child score had more diastolic dysfunction. Serum pro-BNP levels and QTc interval were also higher in patients with diastolic dysfunction. On survival analysis, patients with cirrhotic cardiomyopathy had shorter survival and greater frequency of encephalopathy and hepatorenal syndrome (HRS) episodes as compared with cirrhotic patients without cardiomyopathy, though the differences were not statistically significant. CONCLUSION The study showed that diastolic dysfunction was highly prevalent (56.6% of the study population) in cirrhosis patients. QTc interval and pro-BNP were also significantly raised. Also, complications of cirrhosis like HRS, spontaneous bacterial peritonitis, and hepatic encephalopathy were more common in the cirrhotic cardiomyopathy group.
Collapse
Affiliation(s)
- N Kapoor
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - V Mehta
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - B Singh
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - R Karna
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - S Kumar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India
| | - P Kar
- Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, E23 Nivedita Kunj, Sector-10, R K Puram, New Delhi 110 002, India.
| |
Collapse
|
|
5
|
Non-Alcoholic Cirrhosis and Heart Rate Variability: A Systematic Mini-Review. ACTA ACUST UNITED AC 2020; 56:medicina56030116. [PMID: 32151106 PMCID: PMC7143026 DOI: 10.3390/medicina56030116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/22/2022]
Abstract
Background and Objectives: Cirrhosis is a liver disease that causes about one million deaths annually worldwide. The estimated cirrhosis prevalence ranges from 4.5–9.5% in the general population. Up to 40% of cirrhotic patients are asymptomatic and may be diagnosed late. Studies have described the importance of the functions of the liver and autonomic nervous system (ANS) and their relationship. There is limited information available on non-alcoholic cirrhosis and heart rate variability (HRV), which is a measure of the ANS. This study aimed to evaluate cardiac autonomic modulation through HRV in non-alcoholic cirrhosis individuals reported in previous observational and clinical trial studies. Materials and Methods: We performed a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement using the Medline, Scopus, and Web of Science electronic databases. Five studies were identified and reviewed. Results: HRV was decreased in patients with non-alcoholic cirrhosis, even in the first stage. Conclusions: HRV could be used as a complementary method to improve both the diagnosis and prognosis of non-alcoholic cirrhosis.
Collapse
|
|
6
|
Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. ACTA ACUST UNITED AC 2019; 52:e7809. [PMID: 30785477 PMCID: PMC6376321 DOI: 10.1590/1414-431x20187809] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- M V H Carvalho
- Departamento de Cirurgia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - P C Kroll
- Hospital de Transplante E.J. Zerbini, São Paulo, SP, Brasil
| | - R T M Kroll
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - V N Carvalho
- Hospital Municipal Dr. Mario Gatti, Campinas, SP, Brasil
| |
Collapse
|
|
7
|
Kim SM, George B, Alcivar-Franco D, Campbell CL, Charnigo R, Delisle B, Hundley J, Darrat Y, Morales G, Elayi SC, Bailey AL. QT prolongation is associated with increased mortality in end stage liver disease. World J Cardiol 2017; 9:347-354. [PMID: 28515853 PMCID: PMC5411969 DOI: 10.4330/wjc.v9.i4.347] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/13/2017] [Accepted: 02/20/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the prevalence of QT prolongation in a large series of end stage liver disease (ESLD) patients and its association to clinical variables and mortality.
METHODS The QT interval was measured and corrected for heart rate for each patient, with a prolonged QT cutoff defined as QT > 450 ms for males and QT > 470 ms for females. Multiple clinical variables were evaluated including sex, age, serum sodium, international normalized ratio, creatinine, total bilirubin, beta-blocker use, Model for End-Stage Liver Disease (MELD), MELD-Na, and etiology of liver disease.
RESULTS Among 406 ESLD patients analyzed, 207 (51.0%) had QT prolongation. The only clinical variable associated with QT prolongation was male gender (OR = 3.04, 95%CI: 2.01-4.60, P < 0.001). During the study period, 187 patients (46.1%) died. QT prolongation was a significant independent predictor of mortality (OR = 1.69, 95%CI: 1.03-2.77, P = 0.039). In addition, mortality was also associated with viral etiology of ESLD, elevated MELD score and its components (P < 0.05 for all). No significant reversibility in the QT interval was seen after liver transplantation.
CONCLUSION QT prolongation was commonly encountered in an ESLD population, especially in males, and served as a strong independent marker for increased mortality in ESLD patients.
Collapse
|
|
8
|
Electrocardiographic findings in hepatic cirrhosis and their association with the severity of disease. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2016.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
|
9
|
Electrocardiographic and echocardiographic changes in patients undergoing liver transplant stratified by outcomes. Int J Cardiol 2016; 223:699-700. [PMID: 27568992 DOI: 10.1016/j.ijcard.2016.08.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/03/2016] [Indexed: 11/21/2022]
|
|
10
|
QT Indexes in Cirrhotic Patients: Relationship with Clinical Variables and Potential Diagnostic Predictive Value. Arch Med Res 2015; 46:207-13. [PMID: 25843561 DOI: 10.1016/j.arcmed.2015.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/25/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A wide spectrum of cardiovascular changes characterizes cirrhosis, ranging from subclinical alterations to hyperkinetic syndrome. We looked for ECG markers of ventricular repolarization in a population of patients with cirrhosis in comparison to patients without cirrhosis and we investigated the relationship between these and other clinical and laboratory variables. METHODS In 149 patients with cirrhosis and 152 controls, we measured QT maximum interval (QTmax), QT corrected interval (QTc), QT minimum interval (QTmin), QT dispersion (QTdisp), QT peak and T peak-to-end (TpTe). RESULTS In subjects with cirrhosis, in comparison with controls, we observed a higher mean QTmax, mean QTc, mean QTmin, mean QTdisp and mean TpTe. At Cox regression analysis, diastolic blood pressure and beta-blocker treatment were significantly associated with mean QTmax, hypertension with mean QTmin and mean QTc, diastolic blood pressure, beta-blockers and ACE-inhibitors/ARBs with QT disp, and beta-blockers with TpTe. Analysis of ROC curves showed a significant area under curve towards cirrhosis diagnosis, respectively, for a cut-off value of > 400 msec of QTmax, > 360 msec of QTmin, > 450 msec of QTc, > 105 msec of TpTe and > 55 msec of QTdisp. CONCLUSIONS Our study shows that QT indexes are altered in cirrhotic patients and have a potential diagnostic predictive value.
Collapse
|
|
11
|
Huh IY, Park ES, Kim KI, Lee AR, Hwang GS. Alteration of the QT variability index in end-stage liver disease. Korean J Anesthesiol 2014; 66:199-203. [PMID: 24729841 PMCID: PMC3983415 DOI: 10.4097/kjae.2014.66.3.199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/26/2013] [Accepted: 08/14/2013] [Indexed: 01/06/2023] Open
Abstract
Background A prolonged QT interval can lead to malignant ventricular arrhythmias and sudden cardiac death, and has frequently been found in end-stage liver disease (ESLD). However, myocardial repolarization lability has not yet been fully investigated. We evaluated the QT variability index (QTVI), a marker of temporal inhomogeneity in ventricular repolarization and an abnormality associated with re-entrant malignant ventricular arrhythmias. We determined whether QTVI is affected by the head-up tilt test in ESLD. Methods We assessed 36 ESLD patients and 12 control subjects without overt heart disease before and after the 70-degree head-up tilt test. The electrocardiography signal (lead II) was recorded on a computer with an analog-to-digital converter. The RR interval (RRI) and QT interval were measured after recording 5 min of the digitized electrocardiography. Then, the QT intervals were corrected with Bazett's formula (QTc). QTVI was calculated through the following formula: QTVI = log10 [(QTv/QTm2)/(RRIv/RRIm2)], QTv/RRIv: variance of QTI/RRI, QTm/RRIm: mean of QT interval/RRI. Results Cirrhotic patients exhibited an elevated QTVI. In particular, Child class C patients had a significantly increased QTVI compared to Child class A patients and the control subjects in the supine position. However, the head-up tilt test did not cause a significant difference in QTVI in relation to the severity of ESLD. Conclusions Myocardial repolarization lability was significantly altered in end-stage liver disease. Our data suggest that the severity of ESLD is associated with the degree of the alteration in the QT variability index.
Collapse
Affiliation(s)
- In Young Huh
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Eun Sun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Kang-Il Kim
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - A-Ran Lee
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
|
12
|
Wiese S, Hove JD, Bendtsen F, Møller S. Cirrhotic cardiomyopathy: pathogenesis and clinical relevance. Nat Rev Gastroenterol Hepatol 2014; 11:177-86. [PMID: 24217347 DOI: 10.1038/nrgastro.2013.210] [Citation(s) in RCA: 168] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cirrhosis is known to cause alterations in the systemic haemodynamic system. Cirrhotic cardiomyopathy designates a cardiac dysfunction that includes impaired cardiac contractility with systolic and diastolic dysfunction, as well as electromechanical abnormalities in the absence of other known causes of cardiac disease. This condition is primarily revealed by inducing physical or pharmacological stress, but echocardiography is excellent at revealing diastolic dysfunction and might also be used to detect systolic dysfunction at rest. Furthermore, measurement of circulating levels of cardiac biomarkers could improve the diagnostic assessm+ent. Cirrhotic cardiomyopathy contributes to various complications in cirrhosis, especially as an important factor in the development of hepatic nephropathy. Additionally, cirrhotic cardiomyopathy seems to be associated with the development of heart failure in relation to invasive procedures such as shunt insertion and liver transplantation. Current pharmacological treatment is nonspecific and directed towards left ventricular failure, and liver transplantation is currently the only proven treatment with specific effect on cirrhotic cardiomyopathy.
Collapse
Affiliation(s)
- Signe Wiese
- Centre for Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Jens D Hove
- Department of Cardiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastroenterology Unit, Medical Division, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Søren Møller
- Centre for Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| |
Collapse
|
|
13
|
Qureshi W, Mittal C, Ahmad U, Alirhayim Z, Hassan S, Qureshi S, Khalid F. Clinical predictors of post-liver transplant new-onset heart failure. Liver Transpl 2013; 19:701-10. [PMID: 23554120 DOI: 10.1002/lt.23654] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 03/27/2013] [Indexed: 12/12/2022]
Abstract
Objectives of this study were (1) to evaluate preoperative predictors of systolic and diastolic heart failure in patients undergoing liver transplantation (LT) and (2) to describe the prognostic implications of systolic and diastolic heart failure in these patients. The onset of heart failure after orthotopic LT remains poorly understood. Data were obtained for all LT recipients between January 2000 and December 2010. The primary outcome was post-LT heart failure: systolic (ejection fraction ≤ 50%), diastolic, or mixed heart failure. Patients underwent echocardiographic evaluation before and after LT. Pretransplant variables were evaluated as predictors of heart failure with Cox proportional hazards model. 970 LT recipients were followed for 5.3 ± 3.4 years. Ninety-eight patients (10.1%) developed heart failure in the posttransplant period. There were 67 systolic (6.9%), 24 diastolic (2.5%), and 7 mixed systolic/diastolic (0.7%) heart failures. Etiology was ischemic in 18 (18.4%), tachycardia-induced in 8 (8.2%), valvular in 7 (7.1%), alcohol-related in 4 (4.1%), hypertensive heart disease in 3 (3.1%), and nonischemic in majority of patients (59.2%). Pretransplant grade 3 diastolic dysfunction, diabetes, hypertension, mean arterial pressure ≤ 65 mm Hg, mean pulmonary artery pressure ≥ 30 mm Hg, mean pulmonary capillary wedge pressure ≥ 15 mm Hg, hemodialysis, brain natriuretic peptide level and QT interval > 450 ms were found to be predictive for the development of new-onset systolic heart failure. However beta-blocker use before LT and tacrolimus after LT were associated with reduced development of new-onset systolic heart failure. In conclusion, pretransplant risk factors, hemodynamic variables, and echocardiographic variables are important predictors of post-LT heart failure. In patients undergoing LT, postoperative onset of systolic or diastolic heart failure was found to be an independent predictor of mortality.
Collapse
Affiliation(s)
- Waqas Qureshi
- Department of Internal Medicine, Henry Ford Hospital/Wayne State University School of Medicine, Detroit, MI 48202, USA.
| | | | | | | | | | | | | |
Collapse
|
|
14
|
Diastolic dysfunction in patients with end-stage liver disease is associated with development of heart failure early after liver transplantation. Transplantation 2012; 94:646-51. [PMID: 22918216 DOI: 10.1097/tp.0b013e31825f0f97] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation (LTx) is a life-saving treatment of end-stage liver disease. Cardiac complications including heart failure (HF) are among the leading causes of death after LTx. THE AIM The aim is to identify clinical and echocardiographic predictors of developing HF after LTx. METHODS Patients who underwent LTx at the University of Nebraska Medical Center (UNMC) between January 2001 and January 2009 and had echocardiographic study before and within 6 months after transplantation were identified. Patients with coronary artery disease (>70% lesion) were excluded. HF after LTx was defined by clinical signs, symptoms, radiographic evidence of pulmonary congestion, and echocardiographic evidence of left ventricular dysfunction (left ventricle ejection fraction <50%). RESULTS Among 107 patients (presented as mean age [SD], 55 [10] years; male, 70%) who met the inclusion criteria, 26 (24%) patients developed HF after LTx. The pre-LTx left ventricle ejection fraction did not differ between the HF (69 [7]) and the control groups (69 [7] vs. 67 [6], P=0.30). However, pre-LTx elevation of early mitral inflow velocity/mitral annular velocity (P=0.02), increased left atrial volume index (P=0.05), and lower mean arterial pressure (P=0.03) were predictors of HF after LTx in multivariate analysis. Early mitral inflow velocity/mitral annular velocity greater than 10 and left atrial volume index 40 mL/m2 or more were associated with a 3.4-fold (confidence interval, 1.2-9.4; P=0.017) and 2.9-fold (confidence interval, 1.1-7.5; P=0.03) increase in risk of development of HF after LTx, respectively. CONCLUSIONS This study suggests that elevated markers of diastolic dysfunction during pre-LTx echocardiographic evaluation are associated with an excess risk of HF and may predict post-LTx survival.
Collapse
|
|
15
|
Møller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol 2010; 53:179-90. [PMID: 20462649 DOI: 10.1016/j.jhep.2010.02.023] [Citation(s) in RCA: 229] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/26/2010] [Accepted: 02/04/2010] [Indexed: 12/13/2022]
Abstract
Increased cardiac output was first described in patients with cirrhosis more than fifty years ago. Later, various observations have indicated the presence of a latent cardiac dysfunction, which includes a combination of reduced cardiac contractility with systolic and diastolic dysfunction and electrophysiological abnormalities. This syndrome is termed cirrhotic cardiomyopathy. Results of experimental studies indicate the involvement of several mechanisms in the pathophysiology, such as reduced beta-adrenergic receptor signal transduction, altered transmembrane currents and electromechanical coupling, nitric oxide overproduction, and cannabinoid receptor activation. Systolic incompetence in patients can be revealed by pharmacological or physical strain and during stressful procedures, such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. Systolic dysfunction has recently been implicated in development of renal failure in advanced disease. Diastolic dysfunction reflects delayed left ventricular filling and is partly attributed to ventricular hypertrophy, subendocardial oedema, and altered collagen structure. The QT interval is prolonged in about half of the cirrhotic patients and it may be normalised by beta-blockers. No specific therapy for cirrhotic cardiomyopathy can be recommended, but treatment should be supportive and directed against the cardiac dysfunction. Future research should better describe the prevalence, impact on morbidity and survival, and look for potential treatments.
Collapse
Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Denmark.
| | | |
Collapse
|
|
16
|
S. Møller, J. H. Henriksen. Cardiovascular Dysfunction in Cirrhosis: Pathophysiological Evidence of a Cirrhotic Cardiomyopathy. Scand J Gastroenterol 2009. [DOI: 10.1080/00365520120972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
|
|
17
|
Abstract
Cardiac failure affects the liver and liver dysfunction affects the heart. Chronic and acute heart failure can lead to cardiac cirrhosis and cardiogenic ischemic hepatitis. These conditions may impair liver function and treatment should be directed towards the primary heart disease and seek to secure perfusion of vital organs. In patients with advanced cirrhosis, physical and/or pharmacological stress may reveal a reduced cardiac performance with systolic and diastolic dysfunction and electrophysical abnormalities, termed cirrhotic cardiomyopathy. Pathophysiological mechanisms include reduced beta-adrenergic receptor signal transduction and defective cardiac electromechanical coupling. However, the QT interval is prolonged in approximately half of patients with cirrhosis and it may be improved by beta-blockers. No specific therapy can be recommended but it should be supportive and directed against the heart failure. Transjugular intrahepatic portosystemic shunt insertion and liver transplantation affect cardiac function in portal hypertensive patients and cause stress to the cirrhotic heart, with a risk of perioperative heart failure. The risk and prevalence of coronary artery disease are increasing in cirrhotic patients and since perioperative mortality is high, careful evaluation of such patients with dobutamine stress echocardiography, coronary angiography and myocardial perfusion imaging is required prior to liver transplantation. Future research should focus on beneficial effects of treatment on cardiac function and mortality.
Collapse
Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, 239, Hvidovre Hospital, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark.
| | | | | |
Collapse
|
|
18
|
Mani AR, Montagnese S, Jackson CD, Jenkins CW, Head IM, Stephens RC, Moore KP, Morgan MY. Decreased heart rate variability in patients with cirrhosis relates to the presence and degree of hepatic encephalopathy. Am J Physiol Gastrointest Liver Physiol 2009; 296:G330-8. [PMID: 19023029 PMCID: PMC2643913 DOI: 10.1152/ajpgi.90488.2008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Heart rate variability (HRV) is reduced in several clinical settings associated with either systemic inflammation or neuropsychiatric impairment. The possibility that the changes in HRV observed in patients with neuropsychiatric impairment might relate to the overproduction of inflammatory cytokines does not seem to have been considered in the studies undertaken to date. HRV is decreased in patients with liver cirrhosis but its relationship to the impairment of neuropsychiatric performance, commonly observed in these patients, is unknown. The aim of this study was to investigate the relationship between HRV, hepatic encephalopathy, and production of inflammatory cytokines in patients with cirrhosis. Eighty patients with cirrhosis [53 men, 27 women; mean (+/-1SD) age 54 +/- 10 yr], classified as neuropsychiatrically unimpaired or as having minimal or overt hepatic encephalopathy, and 11 healthy subjects were studied. HRV was assessed by applying Poincaré plot analysis to the R-R interval series on a 5-min ECG. Inflammatory cytokines (TNF-alpha, IL-6, IL-10, and IL-12) were measured in a subgroup of patients. Long-term R-R variability was significantly decreased in the patients with cirrhosis, in parallel with the degree of neuropsychiatric impairment (P < 0.01) and independently of the degree of hepatic dysfunction (P = 0.011). The relative risk of death increased by 7.7% for every 1-ms drop in this variable. Plasma levels of IL-6 significantly correlated with indexes of both HRV and neuropsychiatric performance. The changes observed in HRV and in neuropsychiatric status in patients with cirrhosis are significantly correlated, most likely reflecting a common pathogenic mechanism mediated by inflammatory cytokines.
Collapse
Affiliation(s)
- Ali R. Mani
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Sara Montagnese
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Clive D. Jackson
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Christopher W. Jenkins
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Ian M. Head
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Robert C. Stephens
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Kevin P. Moore
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| | - Marsha Y. Morgan
- Centre for Hepatology, Royal Free Campus, University College London Medical School, University College London; Department of Neurophysiology, Royal Free Hospital, Royal Free Hampstead National Health Service Trust, Hampstead, London; and Critical Care Group, Portex Unit, Institute of Child Health, University College London Medical School, University College London, London, United Kingdom
| |
Collapse
|
|
19
|
Kosar F, Ates F, Sahin I, Karincaoglu M, Yildirim B. QT interval analysis in patients with chronic liver disease: a prospective study. Angiology 2007; 58:218-24. [PMID: 17495272 DOI: 10.1177/0003319707300368] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In previous studies, it has been shown that QT interval prolongation is related to an increased mortality rate in chronic liver disease (CLD). But QT dispersion (QTd) and its clinical significance in CLD has not been well studied. The objectives of this study were to investigate the relation between QTd and severity of the disease and determine its prognostic value in cirrhotic patients. Thirty-three consecutive patients with cirrhosis and 35 sex- and age-matched healthy subjects were studied. QT intervals and QT dispersions were measured on admission, and all intervals were corrected for heart rate according to Bazett's formula. The authors analyzed the potential relationship between QT parameters and the disease severity according to Child-Pugh classification and compared these values between survivors and nonsurvivors after a 3-year follow-up. Child-Pugh classification is used to assess liver function in cirrhosis. Corrected QT (QTc) prolongations were found in 32% of patients with cirrhosis and 5.7% of the healthy controls (p <0.001). The prevalence of increased (>70 ms) corrected QT dispersion (QTcd) was 45% in patients with cirrhosis. According to Child-Pugh criteria: QTd, maximum QT interval (QTmax), corrected QTmax (QTcmax), and QTcd in class C were significantly higher than those of class A and B (p <0.05, for all comparison). But there was no significant difference between class A and B in QTmax, QTcmax, QTd, and QTcd. There were 10 (30%) deaths from all causes during 3-year follow-up in the study group. Cox regression analysis showed that QTd and QTcd were better mortality indicators than QTmax and QTcmax, and Child's classification was the best predictor for mortality among all variables. In conclusion, QT dispersion and corrected QT dispersion parameters were better mortality indicators than other QT interval parameters and also may give additional prognostic information in patients with chronic liver disease.
Collapse
Affiliation(s)
- Feridun Kosar
- Department of Cardiology, Inonu University, Faculty of Medicine, Malatya, Turkey.
| | | | | | | | | |
Collapse
|
|
20
|
Keresztes K, Istenes I, Folhoffer A, Lakatos PL, Horvath A, Csak T, Varga P, Kempler P, Szalay F. Autonomic and sensory nerve dysfunction in primary biliary cirrhosis. World J Gastroenterol 2004; 10:3039-43. [PMID: 15378789 PMCID: PMC4576268 DOI: 10.3748/wjg.v10.i20.3039] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: Cardiovascular autonomic and peripheral sensory neuropathy is a known complication of chronic alcoholic and non-alcoholic liver diseases. We aimed to assess the prevalence and risk factors for peripheral sensory nerve and autonomic dysfunction using sensitive methods in patients with primary biliary cirrhosis (PBC).
METHODS: Twenty-four AMA M2 positive female patients with clinical, biochemical and histological evidence of PBC and 20 age matched healthy female subjects were studied. Five standard cardiovascular reflex tests and 24-h heart rate variability (HRV) analysis were performed to define autonomic function. Peripheral sensory nerve function on median and peroneal nerves was characterized by current perception threshold (CPT), measured by a neuroselective diagnostic stimulator (Neurotron, Baltimore, MD).
RESULTS: Fourteen of 24 patients (58%) had at least one abnormal cardiovascular reflex test and thirteen (54%) had peripheral sensory neuropathy. Lower heart rate response to deep breathing (P = 0.001), standing (P = 0.03) and Valsalva manoeuvre (P = 0.01), and more profound decrease of blood pressure after standing (P = 0.03) was found in PBC patients than in controls. As a novel finding we proved that both time domain and frequency domain parameters of 24-h HRV were significantly reduced in PBC patients compared to controls. Each patient had at least one abnormal parameter of HRV. Lower CPT values indicated hyperaesthesia as a characteristic feature at peroneal nerve testing at three frequencies (2000 Hz: P = 0.005; 250 Hz: P = 0.002; 5 Hz: P = 0.004) in PBC compared to controls. Correlation of autonomic dysfunction with the severity and duration of the disease was observed. Lower total power of HRV correlated with lower CPT values at median nerve testing at 250 Hz (P = 0.0001) and at 5 Hz (P = 0.002), as well as with those at peroneal nerve testing at 2000 Hz (P = 0.01).
CONCLUSION: Autonomic and sensory nerve dysfunctions are frequent in PBC. Twenty-four-hour HRV analysis is more sensitive than standard cardiovascular tests for detecting of both parasympathetic and sympathetic impairments. Our novel data suggest that hyperaesthesia is a characteristic feature of peripheral sensory neuropathy and might contribute to itching in PBC. Autonomic dysfunction is related to the duration and severity of PBC.
Collapse
Affiliation(s)
- Katalin Keresztes
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | | | | | | | | | | | | | | | | |
Collapse
|
|
21
|
Iga A, Nomura M, Sawada Y, Ito S, Nakaya Y. Autonomic nervous dysfunction in patients with liver cirrhosis using 123I-metaiodobenzylguanidine myocardial scintigraphy and spectrum analysis of heart-rate variability. J Gastroenterol Hepatol 2003; 18:651-9. [PMID: 12753146 DOI: 10.1046/j.1440-1746.2003.03044.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND It has been reported that nitric oxide (NO) synthase is induced in patients with liver cirrhosis (LC), and that an excessive production of NO enhances sympathetic nervous function. The present report describes a study of the feasibility of evaluation of abnormalities of autonomic nervous function by 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy and heart-rate variability in patients with LC. METHODS Low-frequency (LF) power, high-frequency (HF) power, LF/HF, and 1/f fluctuations of heart rate variability were examined in 50 patients with LC (LC group), and 50 normal subjects (N group). Echocardiogram, urinary nitrite and nitrate, and cathecholamines were examined. RESULTS Fractional shortening was observed for the hyperdynamic state of patients in the LC group according to Child's A-C classification. Washout rate of MIBG, LF/HF, and blood levels of norepinephrine increased and HF power decreased with the progression of LC. However, the urinary secretion of nitrite and nitrate were significantly increased only in cirrhotic patients with Child C. CONCLUSIONS The present results indicate that autonomic abnormalities appear early in LC, and that these abnormalities can be detected by MIBG myocardial scintigraphy and analysis of heart-rate variability. We consider these methods to be clinically useful for the quantitative detection of hyperdynamic circulation of liver cirrhosis.
Collapse
Affiliation(s)
- Akiko Iga
- Second Department of Internal Medicine, University of Tokushima, Tokushima, Japan
| | | | | | | | | |
Collapse
|
|
22
|
Lazzeri C, La Villa G, Barletta G, Franchi F. 24-hour heart rate variability in patients with vasovagal syncope. Pacing Clin Electrophysiol 2000; 23:463-8. [PMID: 10793435 DOI: 10.1111/j.1540-8159.2000.tb00828.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Since alterations in the autonomic nervous system are thought to play a major role in the pathogenesis of vasovagal syncope, we characterized the chronic autonomic profile of 44 patients with syncope and 20 healthy subjects by means of heart rate variability using 24-hour Holter recordings (time- and frequency-domain indexes), and evaluated whether the different types of responses to tilting (vasodepressive versus cardioinhibitory) could be associated with different cardiac autonomic patterns. Twenty-three patients exhibited a positive response to tilting, which was vasodepressive in 11 patients and cardioinhibitory in 12 patients. All vasodepressive patients had a standard deviation of the averages of NN (SDANN) intervals in all 5-minute segments lower than 100 ms. Patients with vasodepressive syncope also had significantly lower values of RMSSD (the 24-hour square root of the mean of the sum of the squares of differences between adjacent normal RR intervals) than those with cardioinhibitory response, and lacked the day-night rhythm of the low frequency/high frequency ratio. However, only SDANN values correctly identified patients with vasodepressive response to tilting. We conclude that (1) the population of patients with vasovagal syncope is heterogeneous, (2) patients with vasodepressive syncope have a peculiar chronic autonomic profile as assessed by 24-hour heart rate variability analysis, and (3) the evaluation of the autonomic profile in 24-hour Holter recordings could be of value in the diagnosis of patients with syncope.
Collapse
Affiliation(s)
- C Lazzeri
- Department of Internal Medicine, University of Florence School of Medicine, Italy
| | | | | | | |
Collapse
|
|
23
|
Parker BM, Bhatia S, Younossi Z, Henderson JM, Tetzlaff JE. Autonomic dysfunction in end-stage liver disease manifested as defecation syncope: impact of orthotopic liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:497-501. [PMID: 10545537 DOI: 10.1002/lt.500050603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with end-stage liver disease (ESLD) may be at increased risk for syncopal episodes based on their circulatory physiological state. Although a definitive cause for this is not known, several mechanisms have been proposed. In patients with ESLD, defecation syncope may result from a failure of short-term neurocirculatory adaptation to the Valsalva maneuver in the face of a hyperdynamic circulatory state and a decreased effective intravascular volume. We describe 2 patients with ESLD who had repeated episodes of defecation syncope before orthotopic liver transplantation (OLT). The most effective treatment of these syncopal episodes appears to be fluid administration and the use of a pressor agent, such as dopamine, to help maintain both an effective heart rate and intravascular volume. Correction of this altered circulatory physiological state through OLT prevented further syncopal episodes in both patients. A search of the literature failed to show previous reports associating ESLD and defecation syncope. Possible mechanisms favoring this association are reviewed.
Collapse
Affiliation(s)
- B M Parker
- Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | | | | | | |
Collapse
|
|
24
|
Abstract
Impaired homeostasis of the blood volume, with increased fluid and sodium retention, is a prevailing element in the deranged systemic and splanchnic haemodynamics in patients with liver disease. In this review, some basic elements of the circulatory changes that take place and of neurohumoral fluid regulation are outlined in order to provide an update of recent investigations on the neuroendocrine compensation of circulatory and volume dysfunction in chronic liver disease. The underlying pathophysiology is a systemic vasodilatation in which newly described potent vasoactive substances such as nitric oxide and vasodilating peptides seem to play an important role. The development of central hypovolaemia and activation of potent vasoconstricting systems such as the renin-angiotensin-aldosterone system and the sympathetic nervous system lead to a hyperdynamic circulation with increased heart rate and cardiac output. Moreover, patients exhibit an autonomic dys- and hyperfunction with vascular hyporeactivity to pressor stimuli. The circulatory dysfunction may be part of a multiorgan failure with disturbed haemodynamics of various vascular beds, including those of the splanchnic system, kidneys, brain and lungs. It is still an enigma why patients with chronic liver disease are at the same time overloaded and functional hypovolaemic with a hyperdynamic, hyporeactive circulation. Further research is needed to find the solution to this apparent haemodynamic conflict concerning the abnormal neurohumoral fluid regulation in chronic liver disease.
Collapse
Affiliation(s)
- S Møller
- Department of Clinical Physiology, Hvidovre Hospital, University of Copenhagen, Denmark
| | | |
Collapse
|