Which heart rate variability index is an independent predictor of mortality in cirrhosis?

Abstract

Background: Liver cirrhosis is associated with reduced heart rate variability (HRV), which indicates impaired integrity of cardiovascular control in this patient population. There are several different indices for HRV quantification. The present study was designed to: 1) determine which of the HRV indices is best at predicting mortality in patients with cirrhosis; 2) verify if such ability to predict mortality is independent of the severity of hepatic failure. Methods: Ten minutes electrocardiogram was recorded in 74 patients with cirrhosis. Heart rate fluctuations were quantified using statistical, geometrical and non-linear analysis. The patients were followed-up for 18 months and information was collected on the occurrence of death/liver transplantation. Results: During the follow-up period, 24 patients (32%) died or were transplanted for hepatic decompensation. Cox's regression analysis showed that SDNN (total HRV), cSDNN (corrected SDNN), SD1 (short-term HRV), SD2 (long-terms HRV) and spectral indices could predict survival in these patients. However, only SD2 and cSDNN were shown to be independent of MELD in predicting survival. The prognostic value of HRV indices was independent of age, gender, use of beta blockers, and the aetiology of liver disease. Conclusion: Two HRV indices were identified that could predict mortality in patients with cirrhosis, independently of MELD. These indices are potentially useful tools for survival prediction.

Organ System Network Disruption Is Associated With Poor Prognosis in Patients With Chronic Liver Failure

“…Further models using a network approach should include more physiological data, such as heart rate variability and temperature variability indices. Reduced heart rate variability and body temperature variability are known to be inversely associated with increased mortality in cirrhosis patients, where their prognostic value is independent of MELD or Pugh scores (Mani et al, 2009;Bhogal et al, 2019;Bottaro et al, 2020). In a subset of patients investigated, the uncoupling of the autonomic nervous system and cardiovascular system was found to be associated with mortality in liver cirrhosis patients.…”

“…Some studies have suggested the addition of further predictive components such as in the proposal of the MELD-Plus score (Kartoun et al, 2017), while other studies have identified physiomarkers independent to the MELD score in mortality prediction. Montagnese et al (2015) has shown that the addition of an EEG-based hepatic encephalopathy index to MELD improves prognostic accuracy, while Bhogal et al (2019) has defined two heart rate variability indices that predict mortality in cirrhosis patients independently to MELD. The liver remains the primary site of initial pathophysiology development in cirrhosis, and though it is important to include specific liver biomarkers in survivor analysis, the progression of cirrhosis and its downstream effects means that inclusion of involved organ system biomarkers is paramount to reflecting the true complexity of liver cirrhosis.…”

“…This score comprizes of indices including serum bilirubin, serum creatinine, serum sodium, and coagulation factors. Recently, physiological markers (e.g., EEG and heart rate variability indices) have been shown to be independent of MELD in predicting survival (Montagnese et al, 2015;Bhogal et al, 2019). Therefore, conventional clinical scores still have room to improve in reflecting the multisystem nature of liver cirrhosis.…”

Skin temperature variability is an independent predictor of survival in patients with cirrhosis

“…Moreover, it is not known whether temperature variability analysis has a prognostic value in the context of cirrhosis. Recent studies have shown that physiological markers such as heart rate variability (HRV) predict mortality in patients with cirrhosis, independently of other indices of liver failure such as the Child-Pugh and MELD (Model for End-Stage Liver Disease) scores (Bhogal et al, 2019;Satti et al, 2019). It appears that systemic inflammation is involved in the pathogenesis of poor prognosis in cirrhosis (Clària et al, 2016).…”

“…It appears that systemic inflammation is involved in the pathogenesis of poor prognosis in cirrhosis (Clària et al, 2016). Systemic inflammation is linked with reduced HRV (Bhogal et al, 2019;Haddadian et al, 2013) and altered body temperature dynamics in chronic liver failure (Mani et al, 2018), so it is plausible to assess these physio-markers in prediction of poor prognosis in cirrhosis.…”