The Prevalence of Cirrhotic Cardiomyopathy According to Different Diagnostic Criteria

Marcel Razpotnik; Simona Bota; Philipp Wimmer; Michael Hackl; Gerald Lesnik; Hannes Alber; Markus Peck-Radosavljevic


Liver International. 2021;41(5):1058-1069. 

In This Article

Abstract and Introduction


Background and Aims: Recently published criteria by 2019 Cirrhotic Cardiomyopathy Consortium set a lower threshold for reduced ejection fraction to diagnose systolic dysfunction in cirrhotic patients, and stress testing was replaced by echocardiography strain imaging. The criteria to diagnose diastolic dysfunction are in general concordant with the 2016 ASE/EACVI guidelines and differ considerably from the 2005 Montreal recommendations. We aimed to assess the prevalence of cirrhotic cardiomyopathy according to different diagnostic criteria.

Methods: Cirrhotic patients without another structural heart disease, arterial hypertension, portal vein thrombosis, HCC outside Milan criteria and presence of TIPS were enrolled. Speckle-tracking echocardiography was performed by EACVI certified investigators.

Results: A total of 122 patients with cirrhosis fulfilled the inclusion criteria. Overall prevalence of cirrhotic cardiomyopathy was similar for 2005 Montreal and 2019 CCC: 67.2% vs 55.7% (P = .09); and significantly higher compared to 2009 ASE/EACVI criteria: 67.2% vs 35.2% (P < .0001) and 55.7% vs 35.2% (P = .002) respectively. Significantly more patients had diastolic dysfunction according to the 2005 Montreal compared to the 2009 ASE/EACVI and 2019 CCC criteria: 64.8% vs 32.8% (P < .0001) and 64.8% vs 7.4% (P < .0001). Systolic dysfunction was more frequently diagnosed according to 2019 CCC criteria compared to 2005 Montreal (53.3% vs 16.4%,P < .0001) or ASE/EACVI criteria (53.3% vs 4.9%,P < .0001).

Conclusion: Cirrhotic cardiomyopathy was present in around 60% of cirrhotic patients when applying the hepatological criteria. A considerably higher prevalence of systolic dysfunction according to the 2019 CCC criteria was observed. Long-term follow-up studies are needed to establish the validity of these criteria to predict clinically relevant outcomes.


The function of the liver and heart is inseparably linked, and cirrhosis may cause structural abnormalities of the heart in the absence of another cardiac disease.[1] The clinical syndrome of cirrhotic cardiomyopathy (CCM) may affect the patient's outcome, particularly after liver transplantation, surgery or implantation of a transjugular intrahepatic portosystemic shunt (TIPS).[2] CCM is often associated with hyperdynamic circulation, which may induce a high-output cardiac failure similar to those of chronic volume overload of the heart.[3] These hemodynamic changes can result in cardiovascular complications and even death in up to 7%-21% of cases after liver transplantation.[4]

Limited information on the epidemiology of CCM is available to date. Because of the latent nature with near-normal cardiac function at rest, CCM is difficult to detect by conventional echocardiography. In a prospective observational study on extrahepatic complications of cirrhosis, CCM was diagnosed in about 41% of cases and was not associated with the occurrence of hepatopulmonary syndrome.[5] Retrospective analysis of patients undergoing liver transplantation showed a diastolic dysfunction rate between 36% and 53%.[6,7] Another study reported a reduction in left ventricular ejection fraction in 14% of patients after liver transplantation and a seven-fold increase in 1-year mortality.[8] QT interval prolongation has been found in about 50% of cirrhotic patients and is considered to be the earliest sign of cirrhotic cardiomyopathy.[9]

Recently, a group of multidisciplinary experts (2019 Cirrhotic Cardiomyopathy Consortium, 2019 CCC) presented new criteria for the assessment of CCM. According to these criteria, the evaluation of diastolic function is based on contemporary 2016 ASE/EACVI guidelines except few minor revisions.[10] Studies in the general population showed increased specificity of these criteria and a lower prevalence of diastolic dysfunction compared to the 2009 recommendations.[11]

With the development of modern imaging technologies, particularly echocardiographic strain imaging, the old criteria to diagnose CCM, which were first introduced at the Montreal 2005 World Congress of Gastroenterology, became obsolete. Global longitudinal strain (GLS) as a parameter of left ventricular function has been suggested as diagnostic criteria for CCM and needs further evaluation in cirrhotic patients. None of the CCM diagnosis criteria are universally accepted and implemented into clinical practice. Moreover, better collaboration between cardiologists and hepatologists in the evaluation of these patients is needed.

This study aimed to assess the prevalence of CCM according to the different diagnostic criteria.