Abstract 16197: Influence of Coronary Artery Disease on the Prognosis of a Positive Stress Echocardiogram in Patients With Advanced Liver Disease

Abstract

Background: Cardiac complications are the leading cause of mortality after orthotopic liver transplantation (OLT). In the general population, a positive dobutamine stress echocardiogram (DSE) in the absence of coronary artery disease (CAD) still identifies a high risk group whose outcome is similar to those with positive DSE and CAD. DSE is widely employed as a screening method prior to OLT but less is known about the prognostic impact of a positive DSE in the end stage liver disease (ESLD) population and whether CAD also influences their outcome. We investigated the prognostic impact of a positive DSE and clinical factors including CAD in patients with ESLD. Methods: Follow-up data was obtained in 61 liver transplant candidates with positive DSE and coronary angiography for cardiovascular events including angina requiring revascularization, heart failure, infarction, and cardiac death. Event free survival was compared between patients with (22 patients >70% stenosis) and without (39 patients) obstructive CAD and Cox regression was used to identify factors associated with events. Results: Over a mean follow-up of 27 + 28 months, 21 % (8/39) of patients with positive DSE and no CAD had events compared with 46% (10/22) of patients with positive DSE and CAD, p = 0.04. At one year of follow-up, cardiac death had occurred in 8% (3/39) of patients with positive DSE and no CAD, and in 9% (2/22) of those with positive DSE and CAD. Overall, event free survival was significantly better in those without CAD (p = 0.014). Beta blocker use (HR: 4.1, 95% CI: 1.7 - 9.9, p-value = 0.010), CAD (HR: 4.4 95% CI: 1.8- 10.8, p-value = 0.008), and non-alcoholic steatohepatitis (NASH) (HR: 4.9, 95% CI: 2.0 - 11.7, p-value = 0.04) were independently associated with cardiac events. Conclusion: ESLD patients with a positive DSE and no CAD had a one year cardiac mortality that was similar to patients that had a positive DSE and CAD. However, the overall prevalence of cardiac events and the event free survival was significantly worse in the CAD group. Thus, ESLD patients with a positive DSE are at increased risk and the presence of CAD further increases their risk. In addition to CAD, beta blocker use and NASH were independently associated with cardiac events.