Chronotropic incompetence in end-stage liver disease

Abstract

Background Cirrhosis causes alterations in the cardiovascular and autonomic nervous systems and leads to cirrhotic cardiomyopathy (CCM). CCM is defined as cardiac dysfunction characterized by an impaired systolic responsiveness to stress or exercise, and/or impaired diastolic function, as well as electrophysiological abnormalities, including chronotropic incompetence (CI), in the absence of other known cardiac disease. CI is a common feature of autonomic neuropathy in cirrhosis. The aim of the study is to assess the role of cardiac exercise stress test in the diagnosis of CCM. Methods The analysis included 160 end-stage liver disease (ESLD) patients who underwent a cardiac exercise stress test prior to the orthotopic liver transplantation. CI was defined as the inability to achieve the heart rate reserve (HRR). Pertaining to the therapy with beta-blockers: 80% of HRR was achieved in patients not taking beta-blockers and 62% in patients taking beta-blockers. Results In the analyzed population, 68.8% of patients met the criteria for CI. CI was more frequent in the more severe ESLD (with a higher MELD score and in a higher Child-Pugh class). In comparison to the viral hepatitis and other etiologies of ESLD, patients with alcoholic cirrhosis had a significantly lower rest heart rate (HR), lower maximal HR, lower median achieved percentage of maximal predicted HR (MPHR), a smaller percentage of patients achieved ≥ 85% of MPHR and a lower heart rate reserve. No significant relationship between the survival of OLT recipients and presence of chronotropic incompetence regarding to class of Child-Pugh scale, MELD score and etiology of ESLD were found. Conclusions The prevalence of CI is higher among liver transplant candidates than previously described. The altered chronotropic response may differ in regard to the severity of liver disease correlating with both the Child-Pugh and MELD scores, however CI does not seem to influence the long-term survival post OLT. Exercise stress test is a reliable, safe and useful tool for the diagnosis of CCM in liver transplant candidates and should be included in the standard cardiovascular assessment prior to OLT.

Cardiomyopathy in cirrhosis: From pathophysiology to clinical care

“…Główczyńska et al. 65 contended that the exercise stress test is a reliable, safe and useful tool for the diagnosis of CCM in liver transplant candidates and should be included in cardiovascular assessment before liver transplantation.…”

Rate-Responsive Cardiac Pacing: Technological Solutions and Their Applications

“…CI is often observed in obese patients and in patients with type 2 diabetes, trisomy 21, rheumatoid arthritis, end-stage renal disease, kidney transplantation, or COVID-19 [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. In patients with hepatic failure, the altered chronotropic response correlates with the degree of organ failure, making it a valuable criterion in cardiovascular assessment when selecting candidates for liver transplantation [ 21 ]. In patients that have undergone Fontan surgery, chronotropic failure correlates with impaired exercise capacity, liver dysfunction, and platelet abnormalities; the heart rate reserve in these patients may be an indicator of organ complications, and it may serve as a precursor for development of bradyarrhythmia and the future need for treatment with an implantable cardiac electronic device [ 22 ].…”