Prevalence and Undertreatment of Prothrombotic Risk in Advanced Forms of Liver Disease

Introduction. Patients with advanced stage of liver disease (ASLD) are often referred for surgical interventions and are at high risk for operative morbidity and mortality. Surgery in the ASLD patients has inherent risks, including bleeding, cytopenias, altered renal perfusion and coagulopathies. Ischemic heart disease (IHD) and structural cardiac damage (CD), especially if undetected and undertreated, may further increase surgical risk, similarly to the contribute of other established comorbidities, such as chronic kidney disease (CKD) and anemia. Aim of the study was to assess the prevalence of IHD, CD, CKD and anemia in 77 consecutive patients with ASLD at a single liver clinic who received a cardiac consultation to quantify the risk for general and cardiac complications related to surgery. Methods. All patients performed transthoracic echocardiography along with EKG. CD was defined by ≥stage B as per the ACC/AHA classification of congestive heart failure, while IHD was defined when one of the following occurred: previous myocardial infarction, or presence of CAD with at least 1 vessel with ≥ 70% stenosis, or presence of abnormal myocardial perfusion and ischemia scores at stress at an established threshold obtained from myocardial perfusion scintigraphy. CKD was defined by estimated GFR <60 mL/min/1.73 m2 (CKD-EPI). Anemia was also calculated according to the World Health Organization (WHO) guidelines. Results. Liver disease was due to hepatitis in 33 patients (42.8%), alcohol in 14(18.2%), both in 16 (20.8%), and other causes in 14 (18.2%). Over 70% of our patients has CD defined by ≥stage B as per the ACC/AHA. Specifically, 36 (46%) ASLD patients had increased left atrial diameter, 41 ( 53%) had septal or free wall ventricular hypertrophy; abnormal diastolic performance was present in 19 (25%), valvular heart disease was present in 15 (19%), while only 5 (6.5%) had reduced LV ejection fraction. At time of the first visit, 11 patients (14%) had atrial fibrillation, an four additional ASLD patients developed atrial fibrillation at a median follow-up of 22 months. Only one of these patients was receiving antithrombotic treatment, though clinically established contraindication to start anticoagulants was present in one patient only. The frequency of IHD, CKD and anemia was respectively 24%, 27% and 53.3%. Discussion. This observational study provides clues for the increased CD/IHD/CKD/anemia risk profile of ASLD patients. In a sizeble subset of these patients there was a cardioembolic risk that was undertreated.