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Published on: November 7, 2020
Pre-Liver Transplant Cardiac Catheterization Is Associated With Low Rate of Myocardial Infarction and Cardiac
Issa Kutkut1, Rayan Jo Rachwan2, Lava R Timsina3
1Division of Cardiology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY.
Insights
Aggressive cardiac catheterization (CATH) screening for coronary artery disease (CAD) in liver transplant (LT) candidates reduces myocardial infarction (MI) and cardiac mortality. This approach validates prior findings in a larger patient cohort.
Area of Science:
- Cardiology
- Hepatology
- Transplant Surgery
Background:
- Liver transplant (LT) candidates often have underlying coronary artery disease (CAD).
- Previous studies suggested a benefit of increased cardiac catheterization (CATH) frequency in reducing myocardial infarction (MI) incidence.
- A strict protocol using CATH based on risk factors, rather than noninvasive testing alone, was previously piloted.
Purpose of the Study:
- To assess post-LT clinical outcomes using an aggressive CAD screening protocol.
- To validate a previously published CATH-based screening protocol in a larger cohort.
- To evaluate the effectiveness of CATH followed by percutaneous coronary intervention (PCI) for significant CAD in LT candidates.
Main Methods:
- A cohort of 811 LT patients (2010-2016) underwent screening.
- Stress testing was performed in 94% and CATH in 69% of patients.
- CAD severity was assessed, and PCI was performed for significant stenosis (≥50%).
Main Results:
- 10% of patients undergoing CATH had significant CAD requiring PCI.
- Stress echocardiography sensitivity for significant CAD was 37%.
- Increased mortality hazard rates correlated with CAD severity post-CATH.
- One-year outcomes (mortality, MI incidence) were similar to a previous smaller cohort, showing low MI rates (<1%).
Conclusions:
- Stress echocardiography alone is insufficient for reliable CAD screening in LT candidates.
- Aggressive CAD screening with CATH is associated with low MI and cardiac mortality rates.
- The study validates the efficacy of the CATH-based screening protocol in a larger, extended follow-up cohort.
Background And Aims:
A study at Indiana University demonstrated a reduction in myocardial infarction (MI) incidence with increased frequency of cardiac catheterization (CATH) in liver transplant (LT) candidates. A strict protocol for performing CATH based upon predefined risk factors, rather than noninvasive testing alone, was applied to a subgroup (2009-2010) from that study. CATH was followed by percutaneous coronary intervention (PCI) in cases of significant coronary artery disease (CAD; ≥50% stenosis). The current study applies this screening protocol to a larger cohort (2010-2016) to assess post-LT clinical outcomes.
Approach And Results:
Among 811 LT patients, 766 underwent stress testing (94%) and 559 underwent CATH (69%), of whom 10% had CAD requiring PCI. The sensitivity of stress echocardiography in detecting significant CAD was 37%. Predictors of PCI included increasing age, male gender, and personal history of CAD (P < 0.05 for all). Compared to patients who had no CATH, patients who underwent CATH had higher mortality (P = 0.07), and the hazard rates (HR) for mortality increased with CAD severity (normal CATH, HR, 1.35; 95% confidence interval [CI], 0.79-2.33; P = 0.298; nonobstructive CAD, HR, 1.53; 95% CI, 0.84-2.77; P = 0.161; and significant CAD, HR, 1.96; 95% CI, 0.93-4.15; P = 0.080). Post-LT outcomes were compared to the 2009-2010 subgroup from the previous study and showed similar 1-year overall mortality (8% and 6%, P = 0.48), 1-year MI incidence (<1% and <1%, P = 0.8), and MI deaths as a portion of all deaths (3% and 9%, P = 0.35).
Conclusions:
Stress echocardiography alone is not reliable in screening LT patients for CAD. Aggressive CAD screening with CATH is associated with low rate of MI and cardiac mortality and validates the previously published protocol when extrapolated over a larger sample and longer follow-up period.
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