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A simple clinical calculator for assessing cardiac event risk in liver transplant candidates: The cardiovascular risk in orthotopic liver transplantation score

2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 6 Linguagem: Inglês

10.1002/cld.718

2046-2484

Lisa B. VanWagner,

Liver Disease Diagnosis and Treatment

Clinical Liver DiseaseVolume 11, Issue 6 p. 145-148 ReviewFree Access A simple clinical calculator for assessing cardiac event risk in liver transplant candidates: The cardiovascular risk in orthotopic liver transplantation score Lisa B. VanWagner M.D., M.Sc., Corresponding Author Lisa B. VanWagner M.D., M.Sc. lvw@northwestern.edu orcid.org/0000-0002-6264-2573 Department of Medicine, Division of Gastroenterology & Hepatology; and Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, ILLisa B. VanWagner, M.D., M.Sc., Department of Medicine, Division of Gastroenterology & Hepatology and Preventive Medicine, Northwestern University, Feinberg School of Medicine, 676 N St. Clair Street, Suite 1400, Chicago, IL 60611. E-mail: lvw@northwestern.eduSearch for more papers by this author Lisa B. VanWagner M.D., M.Sc., Corresponding Author Lisa B. VanWagner M.D., M.Sc. lvw@northwestern.edu orcid.org/0000-0002-6264-2573 Department of Medicine, Division of Gastroenterology & Hepatology; and Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, ILLisa B. VanWagner, M.D., M.Sc., Department of Medicine, Division of Gastroenterology & Hepatology and Preventive Medicine, Northwestern University, Feinberg School of Medicine, 676 N St. Clair Street, Suite 1400, Chicago, IL 60611. E-mail: lvw@northwestern.eduSearch for more papers by this author First published: 26 July 2018 https://doi.org/10.1002/cld.718Citations: 6 This study was supported by the National Institutes of Health (NIH), National Heart, Lung and Blood Institute (grant K23HL136891). Development of the Cardiovascular Risk in Orthotopic Liver Transplantation score was supported by the NIH (grants F32HL116151 and KL2TR001424), the American Liver Foundation (New York, NY), and an Alpha Omega Alpha Postgraduate Award. The Northwestern Medicine Enterprise Data Warehouse (NMEDW) is funded, in part, by the National Center for Advancing Translational Sciences (NCATS) of the NIH research grant UL1TR001422 to the Northwestern University Clinical and Translational Sciences (NUCATS) Institute. Potential conflict of interest: Nothing to report. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract Watch a video presentation of this article Watch the interview with the author Answer questions and earn CME Abbreviations CAR-OLT Cardiovascular Risk in Orthotopic Liver Transplantation CVD cardiovascular disease LT liver transplantation MELD Model for End-Stage Liver Disease NASH nonalcoholic steatohepatitis NIH National Institutes of Health Liver transplantation (LT) is a high-risk, high-cost intervention that extends life in more than 7,000 patients in the United States each year. However, cardiovascular disease (CVD) negatively affects outcomes among LT recipients. Since 2002, CVD mortality after LT has increased by 50% (Fig. 1), and CVD is now the leading cause of early ( 1 year) mortality.1-4 Approximately 30% of liver transplant recipients will have a CVD complication (myocardial infarction, heart failure, cardiac arrest, atrial fibrillation, pulmonary embolism, or stroke) within 1 year of LT.2-4 Figure 1Open in figure viewerPowerPoint Prevalence of CVD mortality after liver transplantation, United Network for Organ Sharing Database, 2002 to 2011. Since 2002, there has been a 50% increase in the prevalence of CVD mortality after liver transplantation. Data are from Organ Procurement and Transplantation Network 2002 to 2012. CVD outcomes after LT are influenced by LT-specific and traditional CVD risk factors. Current liver allocation policy in the United States is based on Model for End-Stage Liver Disease (MELD) score (range 6-40). The MELD system is intended to allow the greatest access to transplant for the sickest patients, and thus organs are prioritized toward patients with the highest scores. As a result, such patients have a high burden of critical illness.5 Critically ill patients have an increased prevalence of subclinical and clinical CVD.4 In addition, over the past decade there has been a marked rise in the prevalence of CVD comorbid conditions, such as diabetes, among LT candidates related to the ongoing obesity epidemic.6, 7 Nonalcoholic steatohepatitis (NASH), an obesity-related cause of end-stage liver disease that is associated with increased CVD morbidity and mortality,8, 9 is now the second most common indication for LT in the United States, and wait-list registrations for NASH continue to rise.10, 11 Finally, the long-term use of immunosuppression after LT increases the incidence of metabolic complications (hypertension, hyperlipidemia, diabetes, and renal disease) that are known to increase CVD risk (Table 1).12 Thus, LT is associated with unique risk factors and pathology that lead to significant CVD morbidity and mortality. Table 1. Estimated Prevalence of Cardiovascular Risk Factors Among Liver Transplant Recipients CVD Risk Factor Prevalence Rate Metabolic syndromea 50%-60% Systemic hypertension 40%-85% Diabetes mellitus 10%-64% Obesity 24%-64% Dyslipidemia 40%-66% Chronic kidney disease (stage 3-4)b 30%-80% End-stage kidney disease 5%-8% Smoking 10%-40% a Any three of the following: hypertension (systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥85 mm Hg), impaired fasting glucose (fasting glucose ≥100 mg/dL), central obesity (waist circumference >40 inches in men and >35 inches in women), dyslipidemia (triglyceride level ≥150 mg/dL of blood and high-density lipoprotein cholesterol <40 mg/dL in men or <50 mg/dL in women). b Estimated glomerular filtration rate of 15 to 60 mL/min/1.73 m2. Despite documented high CVD risk in LT, until recently there was no LT-specific tool available to help clinicians quantify the risk for intraoperative and immediate postoperative CVD events after an LT operation. The Cardiovascular Risk in Orthotopic Liver Transplantation (CAR-OLT) score, recently published in Hepatology, was developed to address this practice gap.13 The CAR-OLT score was derived in a population of 1,024 LT recipients aged 18 to 75 years at a single large academic transplant center. LT candidates with traditional absolute cardiac contraindications to proceeding with transplant were not included in this analysis. Traditional absolute cardiac contraindications at most transplant centers include: (1) decreased left ventricular systolic function (ejection fraction <45%), (2) decreased right ventricular function and/or significant right ventricular dilation, (3) uncontrolled pulmonary hypertension defined as mean pulmonary artery pressure ≥35 mm Hg at rest despite maximal medical management, (4) significant uncorrectable structural valvular abnormalities (aortic stenosis, mitral stenosis, aortic regurgitation, tricuspid regurgitation), (5) uncorrectable coronary artery disease with induced ischemia on stress testing, (6) significant carotid disease in particular if symptomatic, and (7) diffuse atherosclerotic disease involving multiple organs.14 The CAR-OLT score predicts the 1-year risk for death or hospitalization related to a major CVD event, defined as myocardial infarction, cardiac revascularization (e.g., percutaneous coronary intervention or coronary artery bypass grafting), heart failure, atrial fibrillation, cardiac arrest, pulmonary embolism, or stroke after LT. The score uses a point-based system to determine an individual's 1-year risk for a CVD event based on a set of pretransplant clinical variables that are easily obtained at point-of-care through medical and social history (Table 2). The 1-year CVD event risk ranges from less than 5% (e.g., optimal risk) to as high as 45% or greater (worst-case risk) (Table 2). The goal is for clinicians to use this information to help guide risk discussions with patients. The CAR-OLT score risk calculator is available for use online (https://carolt.us) and is also available for free download on Apple and Android devices through the application stores. Whether use of the CAR-OLT score for risk stratification, and the decision to proceed with more intensive cardiovascular testing or targeted risk factor reduction, would be helpful to improve CVD outcomes after LT requires external validation in other data samples. Ultimately, a multicenter clinical trial would provide the best evidence base for routine use of the CAR-OLT score in clinical practice. Table 2. CAR-OLT Score Components, Point Values Assigned, and Associated 1-Year Post–Liver Transplant Cardiovascular Complication Predicted Risk by Composite CAR-OLT Score *Risk levels are estimated based on actual event rates in the sample population. Risk levels are shaded, ranging from very low absolute risk to very high. Such distinctions are arbitrary but provide a foundation to determine potential need for clinical intervention. Adapted with permission from Hepatology.13 Copyright 2017, American Association for the Study of Liver Diseases. The goals of cardiovascular risk assessment in LT candidates are to: (1) determine intraoperative and immediate postoperative survival, and (2) estimate long-term cardiovascular survival to avoid futility of LT and maximize the benefit of a scarce donor organ. The CAR-OLT score addresses goal 1. However, the optimal immediate CVD and CVD risk factor management of LT candidates and the long-term CVD management of LT recipients require further study. Recently, the American Society for Transplantation Liver and Intestinal and Thoracic and Critical Care Communities of Practice published consensus recommendations based on the available body of evidence regarding the diagnosis and management of CVD in patients with end-stage liver disease before LT.14 The unique physiology of end-stage liver disease can profoundly influence accurate diagnosis, management, and outcomes of underlying cardiac pathology in LT candidates. Thus, risk assessment, with the CAR-OLT calculator or other modalities, is an ongoing process during the LT evaluation that requires a careful evidence-based and multidisciplinary approach to achieve optimal perioperative cardiovascular management of LT candidates. REFERENCES 1 VanWagner LB, Lapin B, Levitsky J, Wilkins JT, Abecassis MM, Skaro AI, Lloyd-Jones DM. High early cardiovascular mortality after liver transplantation. Liver Transpl 2014; 20: 1306- 1316. 2 Albeldawi M, Aggarwal A, Madhwal S, Cywinski J, Lopez R, Eghtesad B, Zein NN. Cumulative risk of cardiovascular events after orthotopic liver transplantation. Liver Transpl 2012; 18: 370- 375. 3 Fussner LA, Heimbach JK, Fan C, Dierkhising R, Coss E, Leise MD, Watt KD. Cardiovascular disease after liver transplantation: when, what, and who is at risk. Liver Transpl 2015; 21: 889- 896. 4 VanWagner LB, Serper M, Kang R, Levitsky J, Hohmann S, Abecassis M, Skaro A, et al. Factors associated with major adverse cardiovascular events after liver transplantation among a national sample. Am J Transplant 2016; 16: 2684- 2694. 5 Wedd JP, Harper AM, Biggins SW. MELD score, allocation, and distribution in the United States. Clin Liver Dis 2013; 2: 148- 151. 6 Saab S, Lalezari D, Pruthi P, Alper T, Tong MJ. The impact of obesity on patient survival in liver transplant recipients: a meta-analysis. Liver Int 2015; 35: 164- 170. 7 Wong RJ, Cheung R, Perumpail RB, Holt EW, Ahmed A. Diabetes mellitus, and not obesity, is associated with lower survival following liver transplantation. Dig Dis Sci 2015; 60: 1036- 1044. 8 Vanwagner LB, Bhave M, Te HS, Feinglass J, Alvarez L, Rinella ME. Patients transplanted for nonalcoholic steatohepatitis are at increased risk for postoperative cardiovascular events. Hepatology 2012; 56: 1741- 1750. 9 Patel SS, Nabi E, Guzman L, Abbate A, Bhati C, Stravitz RT, Reichman T, et al. Coronary artery disease in decompensated patients undergoing liver transplantation evaluation. Liver Transpl 2018; 24: 333- 342. 10 Wong RJ, Aguilar M, Cheung R, Perumpail RB, Harrison SA, Younossi ZM, Ahmed A. Nonalcoholic steatohepatitis is the second leading etiology of liver disease among adults awaiting liver transplantation in the United States. Gastroenterology 2015; 148: 547- 555. 11 Goldberg D, Ditah IC, Saeian K, Lalehzari M, Aronsohn A, Gorospe EC, Charlton M. Changes in the prevalence of hepatitis C virus infection, nonalcoholic steatohepatitis, and alcoholic liver disease among patients with cirrhosis or liver failure on the waitlist for liver transplantation. Gastroenterology 2017; 152: 1090- 1099.e1091. 12 Watt KD. Keys to long-term care of the liver transplant recipient. Nat Rev Gastroenterol Hepatol 2015; 12: 639- 648. 13 VanWagner LB, Ning H, Whitsett M, Levitsky J, Uttal S, Wilkins JT, et al. A point-based prediction model for cardiovascular risk in orthotopic liver transplantation: the CAR-OLT score. Hepatology 2017; 66: 1968- 1979. 14 VanWagner LB, Harinstein ME, Runo JR, Darling C, Serper M, Hall S, et al. Multidisciplinary approach to cardiac and pulmonary vascular disease risk assessment in liver transplantation: an evaluation of the evidence and consensus recommendations. Am J Transplant 2018; 18: 30- 42. Citing Literature Volume11, Issue6June 2018Pages 145-148 FiguresReferencesRelatedInformation