Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis

Tiwari, Nidhish; Margapuri, Jyothi; Katamreddy, Adarsh; Jubbal, Sandeep; Madan, Nidhi

doi:10.1016/j.ijcha.2021.100714

Cited by 6 publications

(6 citation statements)

References 39 publications

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“…However, the positive predictive value of stress echocardiography is modest but the negative predictive value ranges from 90% to 100%. ( 41 ) A previous diagnostic test meta‐analysis ( 42 ) on cardiac screening before LT found that functional testing, although modest (Dobutamine Stress Echocardiography: DSE sensitivity, 0.3 [95% CI, 0.1‐0.5]; specificity, 0.7 [95% CI, 0.4‐0.8]; and Myocardial Perfusion Imaging: MPI sensitivity, 0.6 [95% CI, 0.4‐0.8]; specificity, 0.6 [95% CI, 0.4‐0.8]), is not as effective in assessing CAD in pre‐LT patients compared to the gold‐standard invasive coronary angiogram. In addition, despite having lower nephrotoxicity and risk for bleeding compared to invasive coronary angiogram, coronary computed tomography angiography (CTA) is underused when diagnosing CAD in pre‐LT patients.…”

Section: Discussionmentioning

confidence: 99%

“…Coronary angiography remains to be the gold standard for the detection of CAD, (9) and noninvasive testing including functional testing should not be used alone in diagnosing CAD because of the overall low sensitivity. (39,40) However, coronary angiography also carries risks, such as contrast-induced nephropathy and bleeding in patients with end-stage liver disease, but these risks are low in patients with cirrhosis. (23) Stress echocardiography was commonly used previously as the screening modality of choice for pre-LT CAD assessment.…”

Section: Discussionmentioning

confidence: 99%

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A Meta‐Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

Xiao

Yong

et al. 2021

Liver Transpl

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The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post‐LT outcomes. This systematic review and meta‐analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre‐LT patients. Meta‐analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre‐LT patients. Associated risk factors for CAD in pre‐LT patients and outcomes were evaluated in conventional pairwise meta‐analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%‐24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high‐income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4‐1.4; P = 0.01) and cardiac‐related mortality (OR, 1.2; 95% CI, 1.1‐1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre‐LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre‐LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre‐LT CAD, and more studies are needed to establish consensus.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A Meta‐Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

Xiao

Yong

et al. 2021

Liver Transpl

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“…There have been multiple studies in the past that have shown that DSE has a low sensitivity for detecting CAD in liver transplant candidates ( Table 4 ). The calculated sensitivity has ranged from 13% to 41%, and the specificity has ranged from 47% to 90% [ 4 – 6 , 13 , 14 ]. A systematic review and meta-analysis published in 2021 found that DSE had a sensitivity of just 25% and a specificity of 68%.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Coronary Artery Calcium Scoring with Dobutamine Stress Echo for Detection of Coronary Artery Disease Before Liver Transplantation

et al. 2021

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Background Dobutamine stress echocardiography (DSE) is commonly used for cardiovascular assessment before orthotopic liver transplantation (OLT). The coronary artery calcium score (CACS) is a useful screening tool for coronary artery disease (CAD). We aimed to compare the sensitivity and specificity of DSE and CACS for CAD in OLT candidates. Material/Methods A total of 265 of the 1589 patients who underwent OLT at our center between 2008 and 2019 had preoperative coronary angiography (CAG). Of these, 173 had DSE and 133 had a CT scan suitable for CACS calculation within 1 year of OLT. Patients with a nondiagnostic DSE were excluded (n=100). Two reviewers evaluated CACS on CT scans. The sensitivity/specificity of DSE and CACS for detection of angiographically significant CAD were calculated for patients with both tests (n=36). A separate analysis compared the sensitivity/specificity of a diagnostic DSE (n=73) and CACS (n=133) against CAG for all patients with either test. Results Sensitivity and specificity were 57.1% and 89.7%, respectively, for DSE, compared with 71.4% and 62.1% for CACS at ≥100 Agatston score. For the analysis of all patients with either test, the sensitivity/specificity of DSE for detection of CAD and CACS were 30.8% and 85.0% and 80.0% and 62.8%, respectively. On ROC analysis, CACS was a satisfactory predictor of obstructive CAD (AUC, 0.76±0.06, 95% CI, 0.66–0.87; P <0.001). Conclusions CACS may be an important tool for cardiovascular assessment in patients undergoing OLT. DSE was nondiagnostic in a large percentage of OLT candidates, limiting its use in this population.

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“…Prior practice guidance and consensus statements from the AHA, 9 American Society of Transplantation, 13 and American Association for the Study of Liver Disease 10 recommend that noninvasive stress testing be considered in liver transplantation candidates on the basis of the presence of CHD risk factors regardless of functional status (Table 1). However, because of blunted chronotropy and reduced cardiorespiratory fitness, liver transplantation candidates may have difficulty reaching a target heart rate on both exercise and pharmacological stress testing, resulting in low sensitivity (13%-37%) and suboptimal negative predictive values (75%-80%) for both the detection of significant CHD 93,[114][115][116][117][118][119][120][121] and prediction of postoperative CHD events (Supplemental Table S6). 93 Resting vasodilation in patients with cirrhosis also limits the predictive accuracy of MPS.…”

Section: Limited Role Of Noninvasive Functional Assessment For Chd Ri...mentioning

confidence: 99%

Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association

Cheng¹,

VanWagner²,

Costa³

et al. 2022

Circulation

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Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography–based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches–Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.

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Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis

Cited by 6 publications

References 39 publications

A Meta‐Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

A Meta‐Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients

Comparison of Coronary Artery Calcium Scoring with Dobutamine Stress Echo for Detection of Coronary Artery Disease Before Liver Transplantation

Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association

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