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Utility of Dobutamine Stress Echocardiography in Cardiac Risk Stratification of Patients Undergoing Orthotopic Liver
Akanksha Agrawal1, Deepanshu Jain2, Eyob L Feyssa2
1Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA.
Insights
Dobutamine stress echocardiography (DSE) has limited predictive value for major adverse cardiac events (MACE) and coronary artery disease (CAD) in liver transplant candidates. Standardizing risk stratification and MACE definitions is crucial, alongside exploring alternative cardiac evaluation methods.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Imaging
Background:
- Cardiovascular diseases pose significant risks for patients undergoing orthotopic liver transplantation (OLT).
- Cardiac risk stratification is essential for optimizing outcomes in OLT candidates.
- Dobutamine stress echocardiography (DSE) is a commonly used pre-transplant cardiac evaluation tool.
Purpose of the Study:
- To review the efficacy of dobutamine stress echocardiography (DSE) in predicting cardiac events before orthotopic liver transplantation (OLT).
- To assess the role of DSE in identifying major adverse cardiac events (MACE) and coronary artery disease (CAD) in OLT candidates.
- To highlight the need for standardized cardiac risk assessment protocols in liver transplant recipients.
Main Methods:
- Systematic review of original English-language articles focusing on DSE use in pre-OLT cardiac risk stratification.
- Analysis of 10 studies involving 1699 patients undergoing DSE prior to OLT.
- Evaluation of DSE's performance in predicting MACE and CAD based on reported sensitivity, specificity, PPV, and NPV.
Main Results:
- The composite incidence of MACE was 11.4%. DSE showed low sensitivity (0.12) but high specificity (0.96) for predicting MACE.
- The average prevalence of CAD was 14.4%. DSE demonstrated moderate sensitivity (0.47) and specificity (0.74) for CAD prediction.
- Known CAD significantly increased cardiac event risk post-OLT. DSE had a negative predictive value of 0.89 for both MACE and CAD.
Conclusions:
- Dobutamine stress echocardiography (DSE) exhibits limitations in predicting major adverse cardiac events (MACE) and coronary artery disease (CAD) in orthotopic liver transplantation (OLT) candidates.
- There is a critical need to standardize cardiac risk stratification protocols and MACE definitions for improved reporting and patient care.
- The development and validation of safer, more efficacious alternative methods for cardiac evaluation in OLT candidates are warranted.
Abstract:
Cardiovascular diseases are a major cause of morbidity and mortality in patients after orthotopic liver transplantation (OLT). This review includes major original articles published in the English-language literature of patients who underwent dobutamine stress echocardiography (DSE) before OLT for cardiac risk stratification. Of a total of 10 original articles (total 1699 patients undergoing DSE), 6 studies used DSE to predict major adverse cardiac events (MACE) in patients undergoing OLT and 4 reported the role of DSE in coronary artery disease (CAD) prediction in patients with end-stage liver disease. The composite incidence of MACE was 11.4%. In predicting postoperative MACE, DSE had a composite sensitivity of 0.12 (95% CI, 0.07-0.19), a specificity of 0.96 (95% CI, 0.94-0.97), a positive predictive value (PPV) of 0.26 (95% CI, 0.16-0.38), and a negative predictive value (NPV) of 0.89 (95% CI, 0.88-0.91). The presence of known CAD in a patient was shown to increase the risk of cardiac events after OLT significantly in three of six studies. The average prevalence of CAD was 14.4%. In predicting CAD, DSE had a composite sensitivity of 0.47 (95% CI, 0.32-0.62), specificity of 0.74 (95% CI, 0.68- 0.79), PPV of 0.23 (95% CI, 0.15-0.33), and NPV of 0.89 (95% CI, 0.84-0.93). This review emphasizes the need for standardizing cardiac risk stratification protocol to screen and prevent cardiac morbidity after OLT, standardizing MACE definition to allow more uniform reporting, and the need for safer and efficacious alternatives to DSE in the evaluation of OLT candidates.
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