The Relationship Between Coronary Artery Disease and Cardiovascular Events Early After Liver Transplantation

Samarth S. Patel; Fei-Pi Lin; Viviana A. Rodriguez; Chandra Bhati; Binu V. John; Taylor Pence; Mohammad B. Siddiqui; Adam P. Sima; Antonio Abbate; Trevor Reichman; Mohammad S. Siddiqui


Liver International. 2019;39(7):1363-1371. 

In This Article

Abstract and Introduction


Background & Aims: Cardiovascular complications are major contributors to mortality at liver transplantation (LT). However, the impact of coronary artery disease (CAD) on these complications is not well-understood as the literature is limited by non-invasive assessment of CAD, which is suboptimal in patients with cirrhosis. Thus, the current study evaluated cardiovascular events at LT stratified according to the presence and severity of CAD quantified on coronary angiography.

Methods: All patients who had LT from January 2010 to January 2017 were evaluated (N = 348), but analysis was restricted to patients who had coronary angiography prior to LT (N = 283). Protocol coronary angiography was performed in all patients' ages >50 years, history of CAD, abnormal cardiac stress test or risk factors for CAD. The primary outcome was a cardiovascular composite outcome including myocardial infraction (MI), cardiac arrest, stroke, cardiac death, heart failure or arrhythmia occurring within 4 weeks after LT.

Results: CAD was present in 92(32.5%) patients and 32(11.3%) had obstructive CAD. During the study period, 72(25.4%) patients met the primary cardiovascular outcome, the most common being arrhythmia (N = 59 or 20.8%). Non-ST elevation MI occurred in 11(3.9%) of patients. A total of 10 deaths (3.5%) occurred, of which 6(2.1%) were attributable to cardiac death. There was no evidence of a relationship between the presence and severity of CAD and composite cardiovascular events. In multiple regression modelling, only diabetes [OR 2.62, 95%CI (1.49, 4.64), P < 0.001] was associated with the likelihood of having a cardiovascular event.

Conclusion: Cardiovascular disease mortality is the most important contributor of early mortality after LT but is not related to the severity of CAD.


Cardiovascular disease (CVD) is an important contributor to morbidity and mortality during and immediately after liver transplantation (LT).[1,2] More importantly, the presence and severity of coronary artery disease (CAD) has been linked to worse outcomes at LT.[2] The gold standard for CAD assessment is coronary angiography, but it is often deferred in many patients with decompensated cirrhosis because of perceived higher risk of complications, thereby introducing a selection bias in the published literature.[3–5] This is compounded further by the suboptimal diagnostic performance of non-invasive cardiac testing in patients with cirrhosis because of blunted heart rate response, body habitus, oedema, deconditioning and impaired functional status.[6–8] Thus, it is difficult to interpret the findings of the published literature that have evaluated the impact of underlying CAD on CVD events at the time of LT that used non-invasive cardiac assessment.[9,10] Using coronary angiography, a recent study demonstrated higher prevalence of CAD in potential LT waitlist registrants compared to the general population;[11,12] however, because of relatively small sample size, the association between CAD and CVD events could not be thoroughly interrogated. The study does highlight the fact that CAD is more common among potential LT candidates and its impact should therefore be clearly defined.[11]

The spectrum of liver disease and cause of cirrhosis are rapidly evolving,[13] and while cirrhosis related to non-alcoholic steatohepatitis (NASH) was relatively uncommon during the 1990s and early 2000s, NASH is now the fast-growing indication for LT among new LT waitlist registrants.[14] NASH is closely associated with the metabolic syndrome and CAD[15] and in patients with decompensated cirrhosis because of NASH, the presence and severity of CAD was much higher compared to other aetiologies of cirrhosis.[11] The published literature linking CAD to CVD events largely included patients with viral hepatitis with small contribution from patients with NASH cirrhosis.[1,2] Thus, given these limitations in the published literature, we conducted the following study in patients with decompensated cirrhosis with protocol coronary angiography prior to LT to (a) granularly define the incidence of CVD events, (b) link CVD events to CAD and (c) identify predictors of CVD events at LT.