Cirrhotic cardiomyopathy: A comprehensive review of pathophysiology, diagnosis, and management

Cirrhotic cardiomyopathy (CCM) is a prevalent yet frequently underrecognized cardiac complication of liver cirrhosis, characterized by impaired myocardial contractile reserve, diastolic dysfunction, and electrophysiological abnormalities. Despite its clinical significance, particularly in the setting of liver transplantation, CCM remains largely overlooked. We performed a narrative review of the literature on CCM published up to December 2025, covering pathophysiology, diagnostic criteria, imaging modalities, biomarkers, and management strategies. Depending on the diagnostic criteria used, the prevalence of CCM ranges from 29% to 67.2%. Advanced imaging techniques, particularly global longitudinal strain and cardiac magnetic resonance, enable early detection of subclinical systolic dysfunction. A "toxic triangle" comprising systemic inflammation, metabolic derangements, and neurohormonal activation represents an integrated pathophysiological model that drives myocardial fibrosis and dysfunction. Beta-blockers and aldosterone antagonists remain mainstays of pharmacological management, while liver transplantation is currently the only definitive therapy. CCM is an underrecognized condition with substantial clinical implications. Standardized diagnostic criteria, validated biomarkers, and large-scale prospective studies are urgently needed to improve patient outcomes.