Observational Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 28, 2016; 8(3): 200-206
Published online Jan 28, 2016. doi: 10.4254/wjh.v8.i3.200
Cirrhotic cardiomyopathy: Isn’t stress evaluation always required for the diagnosis?
Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter
Mara Barbosa, Joana Guardado, Carla Marinho, Bruno Rosa, Isabel Quelhas, António Lourenço, José Cotter, Gastroenterology Department, Centro Hospitalar do Alto Ave, 4835 Guimarães, Portugal
Author contributions: All authors had made substantial contributions to the study; Barbosa M, Guardado J, Marinho C, Quelhas I and Cotter J participated in the study concept and design; Barbosa M, Guardado J, Rosa B and Quelhas I were involved in acquisition, analysis and interpretation of the data; Barbosa M, Guardado J and Rosa B performed statistical analysis; Barbosa M and Guardado J drafted the manuscript; Marinho C, Quelhas I, Lourenço A and Cotter J reviewed the manuscript; all authors read and approved the final manuscript.
Institutional review board statement: This study was approved by the Institutional Review Board of Centro Hospitalar do Alto Ave, Guimarães, Portugal.
Informed consent statement: Written informed consent was obtained from every patient included in the study.
Conflict-of-interest statement: Bruno Rosa is a consultant for Given Imagin®. Mara Barbosa, Joana Guardado, Carla Marinho, Isabel Quelhas, António Lourenço and José Cotter certify that they have NO conflit-of-interest.
Data sharing statement: Technical appendix, statistical code, dataset is available from the corresponding at maraisabelbarbosa@net.sapo.pt. Consent was not obtained but the presented data are anonymized and risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mara Barbosa, MD, Gastroenterology Department, Centro Hospitalar do Alto Ave, Rua dos Cutileiros, Creixomil, 4835 Guimarães, Portugal. maraisabelbarbosa@net.sapo.pt
Telephone: +351-933-112632 Fax: +351-253-513592
Received: October 12, 2015
Peer-review started: October 14, 2015
First decision: November 11, 2015
Revised: December 2, 2015
Accepted: December 17, 2015
Article in press: December 18, 2015
Published online: January 28, 2016
Processing time: 101 Days and 7 Hours
Abstract

AIM: To describe the proportion of patients with cirrhotic cardiomyopathy (CCM) evaluated by stress echocardiography and investigating its association with the severity of liver disease.

METHODS: A cross-sectional study was conducted. Cirrhotic patients without risk factors for cardiovascular disease were included. Data regarding etiology and severity of liver disease (Child-Pugh score and model for end-stage liver disease), presence of ascites and gastroesophageal varices, pro-brain natriuretic peptide (pro-BNP) and corrected QT (QTc) interval were collected. Dobutamine stress echocardiography (conventional and tissue Doppler imaging) was performed. CCM was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological stress. Therapy interfering with cardiovascular system was suspended 24 h before the examination.

RESULTS: Twenty-six patients were analyzed, 17 (65.4%) Child-Pugh A, mean model for end-stage liver disease (MELD) score of 8.7. The global proportion of patients with CCM was 61.5%. At rest, only 2 (7.7%) patients had diastolic dysfunction and none of the patients had systolic dysfunction. Dobutamine stress echocardiography revealed the presence of diastolic dysfunction in more 6 (23.1%) patients and of systolic dysfunction in 10 (38.5%) patients. QTc interval prolongation was observed in 68.8% of the patients and increased pro-BNP levels in 31.2% of them. There was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD (P = 0.775, P = 0.532, respectively). Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation (95.0% vs 50.0%, P = 0.028).

CONCLUSION: CCM is a frequent complication of cirrhosis that is independent of liver impairment. Stress evaluation should always be performed, otherwise it will remain an underdiagnosed condition.

Keywords: Dobutamine stress echocardiography, Cirrhotic cardiomyopathy, Cirrhosis, Corrected QT interval prolongation, Liver impairment

Core tip: Our study demonstrates that cirrhotic cardiomyopathy (CCM) is a frequent condition that is independent of the severity of liver disease. Furthermore, it shows that CCM is currently underdiagnosed, even after a comprehensive evaluation at rest. Consequently, a stress test should always be considered in the diagnostic approach to CCM, as it is here. Moreover, an association between corrected QT (QTc) interval prolongation and the presence of gastroesophageal varices was revealed, irrespective of the diagnosis of CCM. As such, the clinical significance of QTc interval prolongation is emphasized and it can be regarded as a marker of severe liver disease.