Risk of acute coronary syndrome and peripheral arterial disease in chronic liver disease and cirrhosis: A nationwide population-based study

A comparison between patients with various etiologies of cirrhosis and examination of cardiac risk factors limiting survival to liver transplantation

BACKGROUND & AIMS

Objectives of this retrospective cohort study were to assess differences in patient survival between etiologies of cirrhosis while on the waitlist for liver transplantation (LT), and to identify cardiac risk factors that predict survival failure while on the waitlist for LT.

METHODS

This single-center retrospective cohort design included adult patients who were listed for LT at a tertiary academic hospital with a high-volume liver transplant center.

RESULTS

Of the 653 patients listed for LT during the study period, 507 (77.6%) survived to transplant and 146 (22.4%) died or clinically deteriorated prior to transplant. Cumulative incidence of death or clinical deterioration did not differ statistically between patient groups (log rank p = .11). In multivariate analysis, compared to patients with NAFLD, there were no significant differences between patients with alcoholic cirrhosis (HR .95, 95%, CI, .62-1.45), cryptogenic cirrhosis (HR 1.31, 95%, CI, .77-2.23), or hepatitis C cirrhosis (HR 1.12, 95%, CI, .66-1.90). However, higher MELD scores (HR = 1.52, 95% CI, 1.12-1.19), severe coronary artery disease (HR = 2.09 95% CI, 1.23-3.55), and tricuspid regurgitation (HR = 2.62, 95% CI, 1.31-5.26) were independently associated with increased risk for survival failure to LT.

CONCLUSIONS

The presence of severe coronary artery disease and tricuspid regurgitation at the time of listing for transplant are associated with survival failure while on the LT waitlist across etiologies of liver disease. Diagnostic assessment of coronary and valvular disease should be considered in all patients undergoing evaluation for LT, such as cardiac catheterization and/or stress echocardiogram.

Unpaired virtual histological staining using prior-guided generative adversarial networks

Fibrosis is an inevitable stage in the development of chronic liver disease and has an irreplaceable role in characterizing the degree of progression of chronic liver disease. Histopathological diagnosis is the gold standard for the interpretation of fibrosis parameters. Conventional hematoxylin-eosin (H&E) staining can only reflect the gross structure of the tissue and the distribution of hepatocytes, while Masson trichrome can highlight specific types of collagen fiber structure, thus providing the necessary structural information for fibrosis scoring. However, the expensive costs of time, economy, and patient specimens as well as the non-uniform preparation and staining process make the conversion of existing H&E staining into virtual Masson trichrome staining a solution for fibrosis evaluation. Existing translation approaches fail to extract fiber features accurately enough, and the decoder of staining is unable to converge due to the inconsistent color of physical staining. In this work, we propose a prior-guided generative adversarial network, based on unpaired data for effective Masson trichrome stained image generation from the corresponding H&E stained image. Conducted on a small training set, our method takes full advantage of prior knowledge to set up better constraints on both the encoder and the decoder. Experiments indicate the superior performance of our method that surpasses the previous approaches. For various liver diseases, our results demonstrate a high correlation between the staging of real and virtual stains (ρ=0.82; 95% CI: 0.73-0.89). In addition, our finetuning strategy is able to standardize the staining color and release the memory and computational burden, which can be employed in clinical assessment.

Survival outcomes of patients with concomitant acute variceal bleeding and acute coronary syndrome, and the role of antiplatelet agents: an institutional experience from a lower middle-income Country

BACKGROUND

There is strong evidence demonstrating the incidence of Acute Coronary Syndrome (ACS) among patients with cirrhosis, with the initiation of antiplatelet therapy being subject to debate due to an increased risk of bleeding. This study aimed to determine mortality among patients presenting with concomitant Acute Variceal Bleeding (AVB) and ACS at Index admission. Furthermore, the recurrence of AVB and ACS among patients discharged with or without antiplatelet therapy was determined.

METHODS

This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan on patients ≥ 18 years of age admitted to our ER with concomitant ACS and AVB between January 2002 to December 2017. Follow-up for 6 months or till death (if < 6 months), was observed, to help determine the incidence of recurrent AVB and ACS. The incidence of AVB and ACS was then compared amongst patient groups based on the usage of anti-platelet drugs on discharge.

RESULTS

A total of 29 patients were included, with a mean age of 58.7 ± 11.0 years. Seven patients died on admission, having worse underlying liver disease. No mortality was reported among the remaining 22 patients. All 22 patients underwent surveillance endoscopy with variceal band ligation until obliteration, as needed. Only 7 patients from the surviving cohort received antiplatelet therapy. After 6.05 ± 1.1 months of follow-up, 1/22 (4.5%) developed recurrent AVB and 2/22 (9.1%) developed cardiovascular events. Importantly, there was no significant difference in the incidence of recurrent AVB (P = 1.000) and ACS (P = 0.091), depending on the use of antiplatelet therapy.

CONCLUSION

Concomitant AVB and ACS is a severe disorder with increased mortality among cirrhotic patients at presentation. The incidence of AVB does not seem to exacerbate with the use of antiplatelet agents, provided successful obliteration of varices is achieved using elective band ligation.

Visualizing novel connections and genetic similarities across diseases using a network-medicine based approach

Understanding the genetic relationships between human disorders could lead to better treatment and prevention strategies, especially for individuals with multiple comorbidities. A common resource for studying genetic-disease relationships is the GWAS Catalog, a large and well curated repository of SNP-trait associations from various studies and populations. Some of these populations are contained within mega-biobanks such as the Million Veteran Program (MVP), which has enabled the genetic classification of several diseases in a large well-characterized and heterogeneous population. Here we aim to provide a network of the genetic relationships among diseases and to demonstrate the utility of quantifying the extent to which a given resource such as MVP has contributed to the discovery of such relations. We use a network-based approach to evaluate shared variants among thousands of traits in the GWAS Catalog repository. Our results indicate many more novel disease relationships that did not exist in early studies and demonstrate that the network can reveal clusters of diseases mechanistically related. Finally, we show novel disease connections that emerge when MVP data is included, highlighting methodology that can be used to indicate the contributions of a given biobank.

Ischemic Heart Disease and Liver Cirrhosis: Adding Insult to Injury

The link between heart and liver cirrhosis was recognized decades ago, although much data regarding atherosclerosis and ischemic heart disease are still missing. Ischemic heart disease or coronary artery disease (CAD) and liver cirrhosis could be associated with characteristic epidemiological and pathophysiological features. This connection determines increased rates of morbidity and all-cause mortality in patients with liver cirrhosis. In the era of a metabolic syndrome and non-alcoholic fatty liver disease pandemic, primary prevention and early diagnosis of coronary artery disease could improve the prognosis of liver cirrhosis patients. This review outlines a summary of the literature regarding prevalence, risk assessment and medical and interventional treatment options in this particular population. A collaborative heart–liver team-based approach is imperative for critical management decisions for patients with CAD and liver cirrhosis.

Management of Acute Coronary Syndrome in Patients with Liver Cirrhosis

Liver cirrhosis (LC) is becoming increasingly common among patients presenting with acute coronary syndromes (ACS) and is associated with significant cardiovascular morbidity and mortality. Management of such patients is complicated by LC related complications. Literature is scarce on the safety of antithrombotic regimens and invasive strategies for ACS in patients with LC, especially those undergoing liver transplant evaluation. Recently there has been evidence that cirrhosis is an independent risk factor for adverse outcomes in ACS. As patients with LC are generally excluded from large randomized trials, definitive guidelines for the management of ACS in this particular cohort are lacking. Many antithrombotic drugs require either hepatic activation or clearance; hence, an accurate assessment of hepatic function is required prior to initiation and dose adjustment. Despite a demonstrated survival benefit of optimal medical therapy and invasive revascularization techniques in LC patients with ACS, both strategies are currently underutilized in this population. This review aims to present currently available data and provide a practical, clinically oriented approach for the management of ACS in LC. Randomized clinical trials in LC patients with ACS are the need of the hour to further refine their management for favorable outcomes.

Clinical factors associated with peripheral artery disease in patients with documented coronary artery disease: A post hoc analysis of the COMPASS trial

BACKGROUND AND AIMS

Patients with coronary artery disease (CAD) who also have peripheral artery disease (PAD) are at high risk of subsequent cardiovascular events and mortality. Despite this, PAD in patients with CAD often remains undiagnosed. The objective of this analysis was to assess clinical factors that predict the presence of PAD in patient with documented CAD who also have PAD.

METHODS

In a post hoc analysis of patients with CAD in the COMPASS trial, we developed separate prediction models for symptomatic lower extremity PAD and documented carotid artery disease (Model 1), asymptomatic lower extremity PAD defined as ABI <0.9 (Model 2) and for any PAD (symptomatic or asymptomatic; Model 3). Using logistic regression models, candidate variables were chosen to predict the presence of PAD. Overall model performance was evaluated for discrimination and calibration using the concordance statistic and Hosmer and Lemeshow Goodness-of-fit chi-square, respectively. The final model was validated by bootstrapping.

RESULTS

Of 23,402 participants, 3484 (14.9%) had a history of symptomatic PAD or carotid artery disease (Model 1), 1422 (5.7%) participants had asymptomatic PAD (Model 2) and 4906 (20.6%) had any PAD (Model 3). Model 1 demonstrated a C-statistic of 0.667 and goodness-of-fit p-value of 0.859. Model 2 demonstrated a C-statistic of 0.626 and goodness-of-fit p-value of 0.250. Model 3 demonstrated a C-statistic of 0.646 and goodness-of-fit p-value of 0.240.

CONCLUSION

Routinely available clinical information is only marginally useful to identify patients with CAD and concomitant PAD.

Liver Disease is Associated with Increased Mortality and Major Morbidity After Infra-Inguinal Bypass but not After Endovascular Intervention

OBJECTIVE

Liver disease increases mortality after abdominal surgery, including endovascular aortic aneurysm repair. However, its effect on mortality and morbidity after endovascular and open management of peripheral vascular disease has not been widely evaluated.

METHODS

The National Surgical Quality Improvement Program was used to evaluate patients undergoing infra-inguinal bypass and endovascular intervention (2005 - 2016). Aspartate aminotransferase to platelet ratio (APRI score) is a non-invasive tool recommended by the World Health Organisation to identify liver disease and was calculated for all patients. A ratio of > 0.5 was used to identify patients with liver fibrosis. Demographics, comorbidities, and 30 day outcomes were evaluated for patients with and without liver fibrosis. A subgroup analysis was completed in patients with APRI scores > 0.5, to evaluate the effect of increasing Model for End-Stage Liver Disease (MELD) scores on outcomes. Multivariable regression was used to account for differences in baseline factors.

RESULTS

In total, 17 603 patients underwent infra-inguinal bypasses. Fibrosis was associated with higher mortality (3.8% vs. 2.4%; p < .001), major complications (23% vs. 20%; p = .020), pulmonary (5.1% vs. 2.9%; p < .001), and renal complications (1.9% vs. 1.1%; p = .007) after bypass. These differences persisted following multivariable adjustment. Altogether, 7 830 patients underwent endovascular intervention. Fibrosis was also associated with higher mortality (4.7% vs. 2.2%; p < .001), pulmonary (3.9% vs. 2.5%; p = .022), and renal complications (1.9% vs. 0.8%; p = .003) after endovascular intervention. After adjustment, only renal complications persisted. In a subgroup analysis of patients with liver fibrosis, morbidity (31% vs. 17%; p < .001) and mortality (7.2% vs. 1.8%; p < .001) increased after bypass among those with MELD scores > 15 but not after endovascular intervention.

CONCLUSION

Liver fibrosis was associated with higher 30 day mortality and major complications after infra-inguinal bypass, with outcomes worsening as MELD scores increased. Surgeons may consider an endovascular first approach in managing peripheral arterial disease among those with liver fibrosis.

Detection of calcified atheromas on panoramic radiographs of cirrhotic patients

BACKGROUND

The present study aimed to investigate the prevalence of calcified atheromas in carotid arteries (CACA) on panoramic radiographs of patients with liver cirrhosis (LC).

METHODS AND RESULTS

A case-control study of 67 individuals with LC (case group) and 67 healthy individuals (control group), matched by gender and age, was performed. In addition to demographic information, data on LC were also collected for the case group. Panoramic radiographs were evaluated by two previously calibrated examiners. The sample consisted predominantly of male individuals (n = 50; 74.62%), with mean age of 55 years old. In the case group, the mean value for the model of end-stage liver disease was 16, and the major aetiology of LC was alcoholism (n = 26; 38.8%). Thirteen (19.4%) LC patients had CACA, whereas only four (5.9%) healthy patients had this condition. LC patients are 3.72 times more likely to have CACA compared to healthy individuals (P = .02). The presence of nephropathies increases the risk of development of atheromas by 18.58 times in cirrhotic individuals (P = .04).

CONCLUSIONS

Cirrhotic patients are more likely to have CACA compared to healthy patients, and this risk increases significantly when kidney disease is involved.

Novel markers of endothelial dysfunction in hepatitis C virus-related cirrhosis: More than a mere prediction of esophageal varices

BACKGROUND

Hepatitis C virus (HCV) infection may affect lipid metabolism by enhancing the circulating levels of inflammatory cytokines, together with its impact on endothelial function.

AIM

To evaluate the potential correlation of changes in lipid profile, carotid intima-media thickness (CIMT), and ankle-brachial index with the severity of fibrosis, grades of esophageal varices (EVs), and fibrosis indices.

METHODS

The study included 240 subjects who were divided into 3 groups; group 1 (n = 90, HCV-related cirrhotic patients with EVs), group 2 (n = 90, HCV-related cirrhotic patients without EVs), and group 3 (n = 60, served as the healthy control group). All patients underwent routine laboratory tests, including a lipid profile assay. Low-density lipoproteins (LDL)/platelet count and platelet/splenic diameter ratios were calculated. Abdominal ultrasonography, CIMT by carotid Doppler, bedside ankle-brachial index (ABI), liver stiffness measurement, and upper gastrointestinal endoscopy were performed.

RESULTS

Multivariate logistic regression revealed that very-low-density lipoprotein (VLDL) (β = 0.988, odds ratio 2.5, P = 0.001), LDL/platelet count ratio (β = 1.178, odds ratio 3.24, P = 0.001), CIMT (β = 1.37, odds ratio 3.9, P = 0.001), and ABI (β = 2.3, odds ratio 5.9, P = 0.001) were the key variables associated with significant fibrosis, EVs and endothelial dysfunction. CIMT and LDL/platelet count ratio were predictive of advanced fibrosis and EVs at cutoff values of 1.1 mm and 1 mm, respectively, with an area under the curve (AUC) of 0.966 and 0.960 (P = 0.001), while VLDL and ABI at a cutoff of 16.5 mg/dL and 0.94 were predictive of advanced fibrosis and EVs with an AUC of 0.891 and 0.823, respectively (P = 0.001).

CONCLUSION

CIMT, ABI, VLDL, LDL/platelet count ratio are good non-invasive predictors of advanced fibrosis, presence of EVs, and endothelial dysfunction in liver cirrhosis.

Time-dependent incidence and risk for myocardial infarction in patients with alcoholic cirrhosis

BACKGROUND

It remains unsettled whether alcoholic cirrhosis is a risk factor for myocardial infarction (MI).

METHODS

We used data from nationwide healthcare registries to study all Danes diagnosed with alcoholic cirrhosis in 1996-2014, and five controls were matched to each of them on gender and age. We excluded everyone with ischaemic heart disease and used Cox regression to estimate the incidence rate ratio of MI adjusted for potential cardiovascular confounders. Further, we described the MI-risk with non-MI death as a competing risk.

RESULTS

We included 22 867 patients (67% men) with a median age of 57 years. During the first year of follow-up, their incidence rate ratio of MI was increased to 1.24 (95% CI: 0.94-1.62), driven by the effect among women (2.13, 95% CI: 1.17-3.87) and those with most severe cirrhosis (1.32, 95% CI: 0.91-1.90). After the first year, the overall incidence rate ratio fell to (0.89, 95% CI: 0.76-1.05). Patients were more likely to die from non-MI causes (33.7% vs 1.0%), which protected them against MI. The overall 1-year MI-risk was similar in patients and controls: 0.38% (95% CI: 0.30-0.47%) vs 0.34% (95% CI: 0.31-0.38%). After five years of follow-up, male patients had lower MI-risk than their controls, whereas women with cirrhosis had an increased MI-risk throughout follow-up.

CONCLUSIONS

The incidence rate of MI was increased the first year following a diagnosis of alcoholic cirrhosis, in particular in women and those with most severe liver disease. Due to the competing risk of non-MI mortality, the MI-risk was not increased.

Association Between Alcoholic Cirrhosis and Hemorrhagic Stroke: A Nationwide Population-based Study

AIMS

This study investigated whether patients with alcoholic cirrhosis have a high risk of hemorrhagic stroke.

METHODS

In this study, 17,094 patients diagnosed with cirrhosis between 2000 and 2010 were identified using the Taiwan National Health Insurance claims data. Identified patients were randomly selected and propensity score matched with individuals without cirrhosis according to age, sex, comorbidities and index year.

RESULTS

The overall incidence rate of stroke was 4.41 and 12.1 per 1000 person-years in the chronic liver disease and cirrhosis (CLDC) with hepatitis B virus (HBV) or hepatitis C virus (HCV) cohort and the alcoholic CLDC cohort, respectively. The alcoholic CLDC cohort exhibited a 4.53-fold higher risk of hemorrhagic stroke (adjusted subhazard ratio [aSHR] = 4.53, 95% confidence interval [CI] = 3.05-6.71) than did the non-CLDC cohort, and the CLDC with HBV or HCV cohort exhibited a 1.40-fold higher risk of hemorrhagic stroke (aSHR = 1.40, 95% CI = 1.10-1.78) than did the non-CLDC cohort. The alcoholic CLDC cohort and the CLDC with HBV or HCV cohort showed an aSHR of 1.80 (95% CI = 1.36-2.40) and 0.95 (95% CI = 0.83-1.07) for ischemic stroke, respectively, compared with the non-CLDC cohort.

CONCLUSION

Alcoholic patients with CLDC had a higher risk of hemorrhagic stroke compared with non-alcoholic patients with CLDC and patients without CLDC.

Overview of the Pathogenesis, Genetic, and Non-Invasive Clinical, Biochemical, and Scoring Methods in the Assessment of NAFLD

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease worldwide. It represents a range of disorders, including simple steatosis, nonalcoholic steatohepatitis (NASH), and liver cirrhosis, and its prevalence continues to rise. In some cases, hepatocellular carcinoma (HCC) may develop. The develop;ment of non-invasive diagnostic and screening tools is needed, in order to reduce the frequency of liver biopsies. The most promising methods are those able to exclude advanced fibrosis and quantify steatosis. In this study, new perspective markers for inflammation, oxidative stress, apoptosis, and fibrogenesis; emerging scoring models for detecting hepatic steatosis and fibrosis; and new genetic, epigenetic, and multiomic studies are discussed. As isolated biochemical parameters are not specific or sensitive enough to predict the presence of NASH and fibrosis, there is a tendency to use various markers and combine them into mathematical algorithms. Several predictive models and scoring systems have been developed. Current data suggests that panels of markers (NAFLD fibrosis score, Fib-4 score, BARD score, and others) are useful diagnostic modalities to minimize the number of liver biopsies. The review unveils pathophysiological aspects related to new trends in current non-invasive biochemical, genetic, and scoring methods, and provides insight into their diagnostic accuracies and suitability in clinical practice.

Epilepsy is associated with higher subsequent mortality risk in patients after stroke: a population-based cohort study in Taiwan

Objective: To use the National Health Insurance Research Database (NHIRD) of Taiwan to determine whether patients with poststroke epilepsy (PSE) in Taiwan have an increased risk of mortality.

Methods: We analyzed the data from the NHIRD of patients (≥40 years) who had received stroke diagnoses between 2000 and 2012. The patients with stroke were divided into PSE and poststroke non-epilepsy (PSN) cohorts and compared against a sex-, age-, comorbidity-, and index-date-matched cohort from normal population. We calculated adjusted HRs (aHRs) and 95% CIs of all-cause mortality risk in these cohorts after adjustment for age, sex, and comorbidities.

Results: Among the poststroke patients, 12.14% constituted the PSE cohort. The cumulative mortality rate was considerably higher in the PSE than in the PSN cohort. The PSE (aHR=4.18, 95% CI=3.91–4.48) and PSN (aHR=1.90, 95% CI=1.83–1.98) cohorts were associated with higher risks of mortality than the comparison cohort. Furthermore, advanced age (≥65 years), male sex, alcohol-related illness, chronic obstructive pulmonary disease, coronary artery disease, diabetes, hypertension, asthma, and cancer would further increase the risk of mortality after a stroke event.

Conclusion: The mortality risk in poststroke patients is approximately two times the likelihood in those with PSE than in those without, and approximately four times higher than that in the normal population. Our findings provide crucial information for clinicians and the government to improve survival after stroke.

Screening of Cardiovascular Disease in Nonalcoholic Fatty Liver Disease: Whom and How?

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide. Patients with NAFLD are at a higher risk of developing cardiovascular disease (CVD). In fact, CVD-related mortality is more common in patients with NAFLD in comparison to liver-related mortality. This association is related to the common metabolic risk factors such as obesity, dyslipidemia, diabetes, and hypertension shared by both NAFLD and CVD, and also there is independent association of NAFLD with CVD because of risk factors such as insulin resistance, systemic inflammation, and atherogenic dyslipidemia. While there is abundant literature on association of NAFLD with CVD, there is sparse literature regarding the screening for CVD in patients with NAFLD. In the current review article, we discuss as to which patients with NAFLD to screen and how to screen for CVD.

Risk and Predisposing Factors for Suicide Attempts in Patients with Migraine and Status Migrainosus: A Nationwide Population-Based Study

Objective: To investigate the risk and risk factors for suicide attempt by patients with regular migraines (RM) and status migrainosus (SM) in Taiwan. Methods: We analyzed a subset of the National Health Insurance Research Database of Taiwan and enrolled patients (≥20 years old) who had ever received a diagnosis of RM or SM between 2000 and 2012 in the RM and SM cohort. The SM cohort included 13,605 patients, the RM cohort had 21,485 patients, and the comparison cohort contained approximately four times that many patients. We calculated the adjusted hazard ratios and 95% confidence intervals (CI) for suicide attempts after adjusting for age, sex, monthly income, urbanization level, occupation, and comorbidities. Results: The SM cohort had a 1.81-fold risk of attempting suicide (95% CI = 1.14–2.89) compared to the comparison cohort. Other factors that predispose patients with SM to attempt suicide include the following: female sex, relatively young age (<50 years old), and low monthly income (<15,000 New Taiwan Dollars, approximately equivalent to 495 US Dollars). Additionally, the risk of attempting suicide only increased in patients who had been diagnosed with SM for longer than five years. Conclusion: SM is associated with a higher risk for suicide attempt in migraineurs in Taiwan. This finding is important to clinicians and government officials seeking to prevent patients from attempting suicide in Taiwan and other similar East Asian countries.

Survival outcome and mortality rate in patients with migraine: a population-based cohort study

Background

Whether the patients with migraine have an elevated mortality risk in Taiwan is unclear.

Methods

We analyzed a subset of the National Health Insurance Research Database of Taiwan and enrolled patients (≥20 years old) who received a diagnosis of migraine between 2000 and 2012. The migraine cohort was further divided into the ones ever with status migrainosus (SM) and non-status migraine (NM) subcohort and compared with a 1:4 age-, sex-, comorbidity-, and index date-matched comparison cohort. We calculated the adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for subsequent mortality risk after adjustment for age, sex, and comorbidities.

Results

Compared with the comparison cohort, the corresponding aHRs for mortality were 0.81 (95% CI = 0.76–0.87), 0.89 (95% CI = 0.80–0.98), and 0.78 (95% CI = 0.72–0.84) in the total migraine, SM, and NM cohorts, respectively. SM, male sex, comorbid alcohol-related illness, depression, and mental disorders were identified as risk factors for subsequent mortality. Comorbid alcohol-related illness significantly increased the mortality risk in patients with migraine.

Conclusion

Taiwanese patients with migraine require comprehensive and universal medical care. These patients would benefit from controlling their migraines and reducing the subsequent mortality.