Blood Pressure Control According to Clinical Practice Guidelines Is Associated With Decreased Mortality and Cardiovascular Events Among Liver Transplant Recipients

Lisa B. VanWagner; Jane L. Holl; Samantha Montag; Dyanna Gregory; Sean Connolly; Megan Kosirog; Patrick Campbell; Stewart Pine; Amna Daud; Dan Finn; Daniela Ladner; Anton I. Skaro; Josh Levitsky; Donald M. Lloyd-Jones


American Journal of Transplantation. 2020;20(3):797-807. 

In This Article

Abstract and Introduction


Data for liver transplant recipients (LTRs) regarding the benefit of care concordant with clinical practice guidelines for management of blood pressure (BP) are sparse. This paper reports on clinician adherence with BP clinical practice guideline recommendations and whether BP control is associated with mortality and cardiovascular events (CVEs) among LTRs. We conducted a longitudinal cohort study of adult LTRs who survived to hospital discharge at a large tertiary care network between 2010 and 2016. The primary exposure was a BP of <140/<90 mm Hg within year 1 of LT. Among 602 LTRs (mean age 56.7 years, 64% men), 92% had hypertension and 38% had new onset hypertension. Less than 30% of LTRs achieved a BP of <140/<90 mm Hg over a mean of 43.2 months. In multivariable models, adjusted for key confounders, BP control post-LT compared with lack of control was associated with a significantly lower hazard of mortality (hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.39, 0.87) and of CVEs (HR 0.65, 95% CI 0.43, 0.97). The association between BP control of <140/<90 mm Hg with improved survival and decreased CVEs in LTRs suggests that efforts to improve clinician adherence to BP clinical practice recommendations should be intensified.


Liver transplantation is a high-risk, high-cost intervention that, at present, extends life in over 8000 patients in the United States each year, with 1-year survival rates >90%.[1] However, cardiovascular (CV) disease is the leading cause of early (<1 year) mortality, and the third leading cause of late (≥1 year) mortality after transplant.[2,3] Up to 30% of liver transplant recipients (LTRs) will experience a CV event (CVE), including myocardial infarction (MI), heart failure, cardiac arrest, atrial fibrillation, thromboembolism, or stroke after transplant.[4,5]

In the general population, CVEs are potentially preventable with intensive management of CV disease risk factors, such as blood pressure (BP).[6] Clinical practice guidelines for BP management in both the general population[7] and LTRs[8] recommend BP lowering in order to prevent CVEs. However, prevalence data and outcomes of controlled BP among LTRs are limited. In a cross-sectional study of 490 LTRs with hypertension in Spain, 68% of participants had controlled BP (<140/<90 or <130/<80 mm Hg if diabetic).[9] However, this study assessed BP only at a single outpatient visit and did not assess the relationship between BP control and clinical outcomes. BP control (<140/<90 mm Hg) has also been reported to be poor among kidney transplant recipients, ranging from 40%-56%, and poor control has been linked to graft failure, increased CVEs, and mortality.[10–13] To our knowledge, BP control has not previously been linked to clinical outcomes among LTRs. We therefore sought to assess clinician adherence to clinical practice guidelines for BP management of LTRs at a large urban tertiary care network and to assess whether BP control predicts mortality and clinical CVEs in this high-risk population.