Abstract
BackgroundThe diagnostic and prognostic utility of risk factors proposed by the 2012 American Heart Association and American College of Cardiology Foundation (AHA/ACCF) Scientific Statement on the cardiac assessment of asymptomatic liver transplantation candidates have not been validated. We investigated whether the sum of risk factors proposed by the AHA/ACCF can identify liver transplant candidates at increased cardiac risk.MethodsIn a retrospective cohort of consecutive liver transplantation recipients, we calculated, for each subject, the pre-transplantation sum of AHA/ACCF risk factors (age > 60 years, prior cardiovascular disease, hypertension, dyslipidemia, diabetes mellitus, smoking, and left ventricular hypertrophy). The primary outcome was the presence of severe coronary artery disease (CAD), defined as ≥70% stenosis or ≥ 50% left main stenosis on pre-transplantation angiography. The secondary outcomes were the composite of cardiac death or myocardial infarction (MI) and the composite of cardiac death, MI, or coronary revascularization.ResultsAmong 220 liver transplant recipients, the sum of AHA/ACCF risk factors had good discriminatory capacity for severe CAD [area under the curve, 0.77; 95% confidence interval (CI), 0.62–0.92; P = 0.007]; having ≥3 risk factors provided 75% sensitivity and 77% specificity for severe CAD. During mean post-transplantation follow-up of 48 ± 31 months, having ≥3 risk factors was associated with increased risk of the secondary composite outcomes of cardiac death or MI [hazard ratio, 2.39; P = 0.044] and cardiac death, MI, or coronary revascularization [hazard ratio, 2.39; P = 0.044].ConclusionsIn patients undergoing cardiac assessment prior to liver transplantation, the sum of risk factors proposed by the AHA/ACCF provides significant diagnostic and prognostic utility. Having ≥3 AHA/ACCF risk factors is a reasonable threshold to prompt non-invasive stress testing in asymptomatic liver transplantation candidates.
Highlights
The diagnostic and prognostic utility of risk factors proposed by the 2012 American Heart Association and American College of Cardiology Foundation (AHA/ACCF) Scientific Statement on the cardiac assessment of asymptomatic liver transplantation candidates have not been validated
The statement indicates that “noninvasive stress testing may be considered in liver transplantation candidates with no active cardiac conditions on the basis of the presence of multiple coronary artery disease (CAD) risk factors regardless of functional status.” [8, 9] These risk factors include age > 60 years, prior cardiovascular disease, hypertension, dyslipidemia, diabetes mellitus, smoking, and left ventricular hypertrophy [8]
There is need for scientific evidence evaluating the use of the AHA/ACCF risk factors in cardiac risk assessment prior to liver transplantation
Summary
The diagnostic and prognostic utility of risk factors proposed by the 2012 American Heart Association and American College of Cardiology Foundation (AHA/ACCF) Scientific Statement on the cardiac assessment of asymptomatic liver transplantation candidates have not been validated. The statement indicates that “noninvasive stress testing may be considered in liver transplantation candidates with no active cardiac conditions on the basis of the presence of multiple CAD risk factors regardless of functional status.” [8, 9] These risk factors include age > 60 years, prior cardiovascular disease, hypertension, dyslipidemia, diabetes mellitus, smoking, and left ventricular hypertrophy [8]. The burden of these risk factors that should prompt non-invasive stress testing in asymptomatic patients has yet to be determined. There is need for scientific evidence evaluating the use of the AHA/ACCF risk factors in cardiac risk assessment prior to liver transplantation
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