Introduction Coronary artery disease (CAD) is associated with increased short-term morbidity and mortality following liver transplantation. As a result, the AASLD recommends that all high risk individuals should undergo CAD evaluation during transplant assessment. The AASLD defines high risk as age over 50 years, a clinical or family history of cardiac disease, known diabetes or a positive smoking history. However, whether such traditional risk factors for CAD are associated with an increased risk of post operative cardiac events in this setting remains unclear.
Aim To determine if the AASLD criteria for CAD evaluation identify patients at risk of an early CE post liver transplant.
Method Retrospective study of 252 consecutive patients who were assessed and subsequently underwent elective liver transplantation 01/2007–03/2010. Variables were recorded at time of transplant assessment. A CE was defined as myocardial infarction, cardiac arrest, cardiogenic pulmonary oedema or complete heart block (Lee et al 1999) by 90-days post transplant. ROC analysis was used to determine appropriate cut-off values.
Results 10 patients had a CE during the specified time period following transplantation. The CE patients were older (age, 59.3 vs 52.9 yrs, p=0.046) than the non CE patients but had similar gender (M:F, 2.3:1 vs 1.9:1, p=0.529) and ethnicity (white:asian:other, 7.6:1:0.3 vs 4:1:0, p=0.605). 216 patients (86.4%) fulfilled the AASLD criteria for CAD evaluation. The CE rate was 5.7% and 0% in patients who did and did not fulfil the criteria, respectively (p=0.225). When considered individually, known cardiac disease (CE 30.0%, non-CE 4.9%, p=0.017), but not smoking (CE 70.0%, non-CE 56.9%, p=0.317), age >50 yrs (CE 90.0%, non-CE 68.8%, p=0.140) or diabetes (CE 40.0%, non-CE 26.8%, p=0.230), was predictive of a CE. The variables that were associated with post transplant CE were age=57 yrs (p=0.010), hypertension (p=0.067), BMI=30 (p=0.052), hyponatraemia (p=0.005), diuretic therapy (p=0.001), MELD=16 (p=0.058) and UKELD=54 (p=0.002). On multivariate analysis, the variables associated with a CE were known cardiac disease (OR 11.1; 95%CI 1.5 to 85.3, p=0.020), age=57 yrs (7.5; 95%CI 1.3 to 42.0, p=0.022), hypertension (OR 4.5; 95%CI 0.9 to 23.0, p=0.072) and UKELD=54 (OR 33.4; 95% CI 3.8 to 291.8, p=0.002). The presence of =2 of these variables predicted a CE with a sensitivity of 90.0%, specificity of 82.7% and NPV of 99.4%.
Conclusion The AASLD criteria for CAD evaluation do not identify patients at risk of an early CE following liver transplantation. Alternative variables may be more appropriate for stratifying patients into low and high risk groups.
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