Etiology of Liver Disease and Cardiovascular Abnormalities in Patients on a Liver Transplantation Waiting List.

BACKGROUND The classical cardiovascular risk factors and changes in the circulatory system secondary to end-stage liver disease (ESLD) are associated with an increased risk of cardiac abnormalities (CAs) in patients waiting for liver transplantation (LTx). The aim of this study was to assess the relationship between the etiology of liver disease and the presence of CAs in patients qualified for LTx. MATERIAL AND METHODS The study enrolled patients qualified to LTx due to ESLD at the Clinical Hospital of the Medical University of Warsaw between 2013 and 2016. Out of 396 patients: 65, 157, 117, and 57 had ESLD due to the alcoholic liver disease (ALD), viral infections (VIR), autoimmune disorders (AUTO), and different etiologies (OTHER), respectively. RESULTS An increased frequency of hypertension and diabetes mellitus were observed in ALD and VIR groups, while for hyperlipidemia, the highest rates were observed in ALD and AUTO groups. Significant differences in CAs rates were observed for resting tachycardia, prolonged QT interval, bradycardia, and left ventricular diastolic dysfunction. After adjustment for age, MELD, and Child-Pugh scores, hyperlipidemia (26% vs. 7-15%, p<0.048) was most frequently observed in the AUTO group, while poor aerobic capacity (49% vs. 21-34%, p<0.009) dominated in the OTHER group. CONCLUSIONS The frequency of hyperlipidemia, and poor aerobic capacity were directly related to the etiology of liver disease, while the remaining associations resulted from effects of age, MELD, and Child-Pugh score.

Pretransplant QT Interval: The Relationship with Severity and Etiology of Liver Disease and Prognostic Value After Liver Transplantation.

BACKGROUND Prolonged QT interval is an integral part of the definition of cirrhotic cardiomyopathy. The aim of this study was to analyze the relationship between QT corrected (QTc) and the etiology and the severity of liver disease in relation to the complications of cirrhosis in candidates for orthotropic liver transplantation (OLTx). MATERIAL AND METHODS From 360 consecutive patients with end-stage liver disease (ESLD) consulted by a designated cardiologist, 160 patients underwent OLTx. The QTc was calculated according to 3 formulas in 151 ECG tracings with good quality. The severity of liver disease was assessed according to Child-Pugh classification and model for end-stage liver disease (MELD). This was a single-center study with register-based follow-up design. RESULTS Prolonged QTc over 440 ms was found in 51 subjects (33.8%), but none had prolonged QTc >500 ms. QTc corrected by Fridericia (F) formula was more suitable for patients with ESLD. We found no correlation between QTc interval and severity of liver disease. The QTc interval was higher in patients with alcoholic cirrhosis when compared to patients with viral hepatitis and ESLD of other etiologies. We observed a higher QTc interval in patients with gastroesophageal varices and encephalopathy. We did not notice any significant difference in the effect of the QTc interval on survival. CONCLUSIONS QTc interval might be associated with etiology and complication of ESLD. The prolonged QT interval is not associated with higher all-cause mortality after OLTx.

The Pre-Transplant Profile of Cardiovascular Risk Factors and Its Impact on Long-Term Mortality After Liver Transplantation.

BACKGROUND Cardiovascular disease (CVD) is an important aggravating factor for orthotopic liver transplantation (OLT) outcomes. CVD still seems to be one of the most common cause of death in the long-term post-transplant period. Nevertheless, there are some limited data regarding the optimal strategy of risk assessment during OLT candidate evaluation. MATERIAL AND METHODS Routine pre-transplant cardiac workup in 360 patients with end stage liver disease (ESLD) included electrocardiogram, echocardiography, and exercise stress testing. The aim of this retrospective study was an analysis of the impact of cardiovascular risk profile on overall mortality in the 2-year follow-up of 160 patients who underwent liver transplantation. RESULTS Cardiovascular risk factors or a history of CVD were found in 23.1% of patients who received transplants. The cardiovascular risk factors most common in our group of transplant recipients with ESLD were: diabetes (26.3%), hypertension (25.6%), and hepatopulmonary syndrome (23.1%). Only 3.8% of patients had a positive exercise test. Coronary angiography revealed at least 50% stenosis in some epicardial arteries in 1.9% of patients. The risk of death in long-term follow-up of liver transplant recipients was most strongly associated with 3 cardiac variables: history of coronary artery disease (CAD), angiographically confirmed coronary stenosis, and reduced ejection fraction (EF). CONCLUSIONS Our study identified pre-transplant CAD with its consequences as a factor associated with increased risk of negative post-transplant outcomes.

Heart failure patients with a previous coronary revascularization: results from the ESC-HF Registry.

BACKGROUND: Coronary revascularization is common in heart failure (HF). AIMS: Clinical characteristic and assessment of in-hospital and long-term outcomes in patients hospitalized for HF with or without a previous percutaneous coronary intervention (PCI) or a coronary artery bypass grafting (CABG). METHODS: The primary endpoint (PE) (all-cause death) and the secondary endpoint (SE) (all-cause death or hospitalization for HF-worsening) were assessed at one-year in 649 inpatients of the ESC-HF Pilot Survey. Additionally, occurrence of death during index hospitalization was evaluated. RESULTS: PCI/CABG-patients (32.7%) were more frequently male, smokers, had myocardial infarction, hypertension (HT), peripheral artery disease and diabetes. The non-PCI/CABG-patients more often had a cardiogenic shock and died in-hospital. The PE occurred in 33 of the 212 PCI/CABG-patients (15.6%) and in 56 of the 437 non-PCI/CABG-patients (12.8%; P=0.3). The SE occurred in 82 of the 170 PCI/CABG-patients (48.2%) and in 122 of the 346 non-PCI/CABG-patients (35.3%; P=0.01). Independent predictors of the PE in the PCI/CABG-patients were: lower left ventricular ejection fraction, use of antiplatelets; in the non-PCI/CABG-patients were: age, ACS at admission. Independent predictors of the SE in the PCI/CABG-patients were: diabetes, NYHA (New York Heart Association) class at admission, HT; in the non-PCI/CABG-patients were: NYHA class, haemoglobin at admission. Serum sodium concentration at admission was a predictor of the PE and the SE in both groups. Heart rate at discharge was a predictor of the PE and the SE in the non-PCI/CABG patients. CONCLUSIONS: The revascularized HF patients had a similar mortality and higher risk of death or hospitalizationsat 12 months compared with the non-PCI/CABG-patients. The revascularized patients had more comorbidities, while the non-PCI/CABG-patients had a higher incidence of cardiogenic shock and in-hospital mortality.

Diagnosis, Clinical Course, and 1-Year Outcome in Patients Hospitalized for Heart Failure With Preserved Ejection Fraction (from the Polish Cohort of the European Society of Cardiology Heart Failure Long-Term Registry).

Compared with heart failure (HF) with reduced ejection fraction (HF-REF), the diagnosis of HF with preserved EF (HF-PEF) is more challenging. The aim of the study was to assess the prevalence of HF-PEF among patients hospitalized for HF, to evaluate the pertinence of HF-PEF diagnosis and to compare HF-PEF and HF-REF patients with respect to outcomes. The analysis included 661 Polish patients hospitalized for HF, selected from the European Society of Cardiology (ESC)-HF Long-Term Registry. Patients with an EF of ≥50% were included in the HF-PEF group and patients with an EF of <50% - in the HF-REF group. The primary end point was all-cause death at 1 year. The secondary end point was a composite of all-cause death and rehospitalization for HF at 1 year. HF-PEF was present in 187 patients (28%). Of those 187 patients, mitral inflow pattern was echocardiographically assessed in 116 patients (62%) and classified as restrictive/pseudonormal in 37 patients (20%). Compared with HF-REF subjects, patients with HF-PEF were older, more often female, and had a higher prevalence of hypertension, atrial fibrillation and sleep apnea. Despite lower B-type natriuretic peptide concentrations and lower prevalence of moderate-to-severe mitral regurgitation in patients with HF-PEF, congestive symptoms at admission were as severe as in patients with HF-REF. There were no significant differences in in-hospital mortality between the HF groups. One-year mortality was high in both groups (17% in HF-PEF vs 21% in HF-REF, p = 0.22). There was a trend toward a lower frequency of the secondary end point in the HF-PEF group (32% vs 40%, p = 0.07). In conclusion, in clinical practice, even easily obtainable echocardiographic indexes of diastolic dysfunction are relatively rarely acquired. One-year survival rate of patients with HF-PEF is not significantly better than that of patients with HF-REF.

Clinical characteristics and predictors of one-year outcome of heart failure patients with atrial fibrillation compared to heart failure patients in sinus rhythm.

BACKGROUND: Atrial fibrillation (AF) frequently coexists with heart failure (HF). AIM: To assess clinical characteristics and to identify predictors of one-year outcome of patients hospitalised for HF, depending on whether they were in sinus rhythm (SR) or had AF. METHODS: The study included Polish patients hospitalised for HF, participating in the Heart Failure Pilot Survey of the European Society of Cardiology, who were followed for 12 months after discharge. Patients with paced heart rhythm were excluded from the study. The primary endpoint was all-cause death at 12 months. RESULTS: The final analysis included 587 patients. AF occurred in 215 (36.6%) patients. Compared to patients in SR, patients with AF were older, more often had a history of previous HF hospitalisation, were characterised by a higher New York Heart Association (NYHA) class, higher heart rate, and lower diastolic blood pressure at hospital admission, and had higher serum creatinine and lower haemoglobin concentration at admission. In-hospital mortality was higher in AF patients compared to SR patients (5.1% vs. 2.4%, respectively), but the difference did not reach statistical significance (p = 0.1). The primary endpoint occurred in 41 of 215 AF patients (19.1%) and in 40 of 372 SR patients (10.8%; p = 0.006). In a multivariate analysis, predictors of the primary endpoint in AF patients were: higher NYHA class at hospital admission (p = 0.02), higher admission heart rate (p = 0.04), lower admission serum sodium concentration (p = 0.0001), and higher heart rate at discharge (p = 0.01). In patients with SR, independent predictors of the primary endpoint included: older age (p = 0.007), lower serum sodium concentration at admission (p = 0.0006), and higher heart rate at discharge (p = 0.008). CONCLUSIONS: Patients with HF and concomitant AF differ significantly from HF patients in SR. In the studied group of real-world HF patients, serum sodium concentration at hospital admission and heart rate at hospital discharge were independent prognostic factors in patients with AF and in patients in SR. In contrast to SR patients, heart rate at hospital admission in AF patients was also predictive of long-term mortality.

Predictors of one-year outcome in patients hospitalised for heart failure: results from the Polish part of the Heart Failure Pilot Survey of the European Society of Cardiology.

BACKGROUND: Over the last few decades, the incidence and prevalence of chronic heart failure (HF) have been constantly increasing. AIM: To identify predictors of one-year mortality and hospital readmissions in patients discharged after hospitalisation for HF. METHODS: The study included Polish patients who agreed to participate in the Heart Failure Pilot Survey of the European Society of Cardiology and were followed for 12 months. The primary endpoint was all-cause death at 12 months. The secondary endpoint was a composite of all-cause death and readmission for cardiac causes at 12 months. RESULTS: The final analysis included 629 patients. The primary end point occurred in 68 of 629 patients (10.8%). In multivariate analysis, independent predictors of one-year mortality were: higher New York Heart Association (NYHA) class at admission (odds ratio [OR] 1.90; 95% confidence interval [CI] 1.01-3.59; p = 0.0478), inotropic support during hospitalisation (OR 3.95; 95% CI 1.49-10.47; p = 0.0056), and lower glomerular filtration rate at discharge (OR 0.978; 95% CI 0.961-0.995; p = 0.0117). The secondary endpoint occurred in 278 of 503 patients (55.3%). In multivariate analysis, predictors of secondary endpoint were a history of previous coronary revascularisation (OR 2.403; 95% CI 1.221-4.701; p = 0.002) and inotropic support during hospitalisation (OR 2.521; 95% CI 1.062-5.651; p = 0.009). CONCLUSIONS: Patients discharged after hospitalisation for HF remained at high risk of death and hospital readmission. A previous history of coronary revascularisation, decreased renal function, and worse clinical status at admission with the need for inotropic support were predictors of one-year outcome in Polish patients hospitalised for HF.

Clinical characteristics and 1-year outcome of hyponatremic patients hospitalized for heart failure.

INTRODUCTION: Previous studies have shown that hyponatremia is associated with unfavorable prognosis in patients with heart failure (HF). However, only few studies aimed at the evaluation of long-term outcome in hyponatremic patients hospitalized for HF. OBJECTIVES: The aim of this study was to assess clinical characteristics and 1-year outcome of patients hospitalized for HF with hyponatremia at hospital admission. PATIENTS AND METHODS: The study included 641 Polish participants of the HF Pilot Survey of the European Society of Cardiology. The primary endpoint was all-cause death at 1 year since index hospitalization. The secondary endpoint was all-cause death or rehospitalization for decompensated HF during a 1-year follow-up. RESULTS: Hyponatremia occurred in 15.8% of 641 patients. On admission, hyponatremic patients were characterized by a higher New York Heart Association class, lower blood pressure, lower body mass index, and higher creatinine and lower hemoglobin concentrations on admission. Compared with normonatremic individuals, hyponatremic patients were at a higher risk of in-hospital death (1.9% vs 9.9%, P <0.0001), death at 1 year (10.4% vs 31.7%; P <0.0001), and death or rehospitalization at 1 year (35.9% vs 56.5%; P <0.0001). In multivariate analyses, hyponatremia was predictive of both the primary (hazard ratio [HR], 3.07; 95% confidence interval [CI], 1.94-4.87; P <0.0001) and secondary endpoints (HR, 1.71; 95% CI, 1.16-2.52; P = 0.007). Hyponatremia was an independent predictor of the primary endpoint also in a subgroup of 621 patients who survived to hospital discharge (HR , 2.11; 95% CI, 1.15-3.86; P = 0.02). CONCLUSIONS: Hyponatremia is a common finding in patients hospitalized for HF. Even in patients who survive to hospital discharge, hyponatremia on admission remains an independent predictor of death in long-term follow-up.

Netrin-1 and semaphorin 3A predict the development of acute kidney injury in liver transplant patients.

Acute kidney injury (AKI) is a serious complication after liver transplantation. Currently there are no validated biomarkers available for early diagnosis of AKI. The current study was carried out to determine the usefulness of the recently identified biomarkers netrin-1 and semaphorin 3A in predicting AKI in liver transplant patients. A total of 63 patients' samples were collected and analyzed. AKI was detected at 48 hours after liver transplantation using serum creatinine as a marker. In contrast, urine netrin-1 (897.8 ± 112.4 pg/mg creatinine), semaphorin 3A (847.9 ± 93.3 pg/mg creatinine) and NGAL (2172.2 ± 378.1 ng/mg creatinine) levels were increased significantly and peaked at 2 hours after liver transplantation but were no longer significantly elevated at 6 hours after transplantation. The predictive power of netrin-1, as demonstrated by the area under the receiver-operating characteristic curve for diagnosis of AKI at 2, 6, and 24 hours after liver transplantation was 0.66, 0.57 and 0.59, respectively. The area under the curve for diagnosis of AKI was 0.63 and 0.65 for semaphorin 3A and NGAL at 2 hr respectively. Combined analysis of two or more biomarkers for simultaneous occurrence in urine did not improve the AUC for the prediction of AKI whereas the AUC was improved significantly (0.732) only when at least 1 of the 3 biomarkers in urine was positive for predicting AKI. Adjusting for BMI, all three biomarkers at 2 hours remained independent predictors of AKI with an odds ratio of 1.003 (95% confidence interval: 1.000 to 1.006; P = 0.0364). These studies demonstrate that semaphorin 3A and netrin-1 can be useful early diagnostic biomarkers of AKI after liver transplantation.

Resting heart rate at hospital admission and its relation to hospital outcome in patients with heart failure.

BACKGROUND: Resting heart rate (HR) has been proven to influence long-term prognosis in patients with chronic heart failure (HF). The aim of this study was to assess the relationship between resting HR at hospital admission and hospital outcome in patients with HF. METHODS: The study included Polish patients admitted to hospital due to HF who agreed to participate in Heart Failure Pilot Survey of the European Society of Cardiology. RESULTS: The final analysis included 598 patients. Median HR at hospital admission was 80 bpm. In univariate analyses, higher HR at admission was associated with more frequent use of inotropic support (p = 0.0462) and diuretics (p = 0.0426), worse clinical (New York Heart Association - NYHA) status at discharge (p = 0.0483), longer hospital stay (p = 0.0303) and higher in-hospital mortality (p = 0.003). Compared to patients who survived, patients who died during hospitalization (n = 21; 3.5%) were older, more often had a history of stroke or transient ischemic attack and were characterized by higher NYHA class, higher HR at admission, lower systolic and diastolic blood pressure at admission, lower ejection fraction, lower glomerular filtration rate, and lower natrium and hemoglobin concentrations at hospital admission. In multivariate analysis, higher HR at admission (OR 1.594 [per 10 bpm]; 95% CI 1.061-2.395; p = 0.0248) and lower natrium concentration at admission (OR 0.767 [per 1 mmol/L]; 95% CI 0.618-0.952; p = 0.0162) were the only independent predictors of in-hospital mortality. CONCLUSIONS: In patients with HF, higher resting HR at hospital admission is associated with increased in-hospital mortality.