The predictive value of transaminases at admission in patients hospitalized for heart failure: findings from the RO-AHFS registry

Abstract

Background: Transaminases are commonly elevated in both the inpatient and ambulatory settings in heart failure (HF). Aims: To determine the prevalence and degree of elevated transaminase levels at admission and to evaluate the association between transaminase levels and in-hospital morbidity and mortality. Methods: Over a 12-month period, the Romanian Acute Heart Failure Syndromes (RO-AHFS) registry enrolled consecutive patients hospitalized for HF at 13 medical centres. A post-hoc analysis of the 489 patients (15.2%) with alanine transaminase (ALT) and aspartate transaminase (AST) (upper limits of normal 31 IU/l and 32 IU/l, respectively) measured at baseline was performed. In-hospital mortality was compared across quartiles using multivariable Cox regression models. Results: The prevalences of elevated ALT and AST were 28% and 24% and the medians (interquartile range) were 22 (16-47) and 23 (16-37 IU/L). Patients with elevated transaminases more commonly had right HF, cardiogenic shock, or an ejection fraction <45%. Patients with an ALT in the highest quartile were more likely to present with hypotension and a low pulse pressure, to have electrocardiographic evidence of left ventricular dyssynchrony and echocardiographic findings including increased left ventricular dimensions, reduced left ventricular ejection fraction, and valvular heart disease, to require inotropic or vasopressor support during hospitalization, and to report lower β-blocker and angiotensinconverting enzyme inhibitor utilization. After adjusting for potential confounders, ALT was directly associated with BUN increases ≥10 mg/dl, necessity for intensive care unit admission, and longer length of stay. Patients in the highest quartile of ALT experienced significantly higher rates of all-cause mortality. Conclusions: In patients hospitalized for HF, there is a graded relationship between admission transaminase levels and surrogates for in-hospital morbidity, while more pronounced elevations of ALT predict in-hospital mortality independent of known prognostic indicators.

Liver function tests in patients with acute heart failure and associated outcomes: insights from ASCEND‐HF

“…This is consistent with the current understanding of acute cardiogenic liver injury . In haemodynamically unstable HF patients, hypotension alone is not always sufficient to cause elevated aminotransferase levels . As demonstrated in this analysis, participants in ASCEND‐HF frequently had evidence of hepatic congestion, but the exclusion criteria, including risk for significant hypotension, recent or active need for intravenous inotropic support, and acute coronary syndrome, likely prevented enrolment of patients at increased risk for acute cardiogenic liver injury.…”

Impaired hepato‐renal function defined by the MELD XI score as prognosticator in acute heart failure

“…There are grounds to believe that episodes of acute heart failure (AHF) may cause multi‐organ (kidney, liver, heart) damage/dysfunction, which leads to progression of the disease and unfavourably affects outcomes . Traditionally, an organ damage/dysfunction is assessed in isolation, whereas in practice several organs may be affected, which can be a marker of a more severe course of AHF.…”

Cardiac amyloidosis: a challenging diagnosis

“…We considered that the passive hepatic congestion added to the amyloid deposition in hepatic vessel walls could lead to hepatocytes ischemia and, consequently, an increase in hepatic enzymes 14 - 16. Recently, a study involving 489 patients diagnosed with heart failure (independently of the staging) evidenced elevated determination of transaminases in 25% of patients 17. Passive hepatic congestion due to increased central venous pressure may cause elevations of liver enzymes and both direct and indirect serum bilirubin.…”