Diastolic Dysfunction Is a Predictor of Poor Survival in Patients with Decompensated Cirrhosis

Association of left ventricular diastolic dysfunction with inflammatory activity, renal dysfunction, and liver-related mortality in patients with cirrhosis and ascites

Left ventricular diastolic dysfunction (LVDD) is the predominant cardiac abnormality in cirrhosis. We investigated the association of LVDD with systemic inflammation and its impact on renal function, occurrence of hepatorenal syndrome (HRS) and survival in patients with cirrhosis and ascites. We prospectively enrolled 215 patients with cirrhosis and ascites. We evaluated the diagnosis and grading of LVDD by Doppler echocardiography, inflammatory markers, systemic hemodynamics, vasoactive factors, radioisotope-assessed renal function and blood flow, HRS development and liver-related mortality. LVDD was diagnosed in 142 (66%) patients [grade 2/3: n  = 61 (43%)]. Serum lipopolysaccharide-binding protein (LBP), plasma renin activity (PRA) and glomerular filtration rate (GFR) were independently associated with the presence of grade 2/3 LVDD and the severity of diastolic dysfunction. Serum tumor necrosis factor-α, cardiac output and plasma noradrenaline were also independently associated with the presence of grade 2/3 LVDD. The diastolic function marker E / e ' was strongly correlated with serum LBP ( r  = 0.731; P  < 0.001), PRA ( r  = 0.714; P  < 0.001) and GFR ( r  = -0.609; P  < 0.001) among patients with LVDD. The 5-year risk of HRS development and death was significantly higher in patients with grade 2/3 LVDD compared to those with grade 1 (35.5 vs. 14.4%; P  = 0.01 and 53.3 vs. 28.2%; P  = 0.03, respectively). The occurrence and severity of LVDD in patients with cirrhosis and ascites is closely related to inflammatory activity. Advanced LVDD is associated with baseline circulatory and renal dysfunction, favoring HRS development, and increased mortality.

A case-cohort study of left ventricular diastolic dysfunction in patients with cirrhosis: the liver-heart axis

Background

Left ventricular diastolic dysfunction (LVDD) is an early manifestation of cirrhotic cardiomyopathy. Few studies have addressed its clinical significance in cirrhosis. We assessed the association of LVDD with the factors affecting cirrhosis patients' severity, complications, and survival.

Methods

A total of 203 cirrhosis patients were enrolled and underwent investigations, including 2-dimensional echocardiography with tissue Doppler imaging, and 139 patients with LVDD (cases) were compared with 64 patients without LVDD (controls). Logistic regression and Kaplan-Meier analysis were applied.

Results

Mean age was 52.76±10 years. Among LVDD patients, 56% had grade-1, and 44% had grade-2 LVDD. Cirrhosis related to NASH had a more significant association with LVDD (P<0.001) than other etiologies. LVDD was significantly associated with a greater incidence of Child-Turcotte-Pugh (CTP) class C (P<0.001), higher model for end-stage liver disease scores (P=0.001), duration of cirrhosis >2 years since diagnosis (P=0.028), ascites (P<0.001), hepatic encephalopathy (P<0.010), hepatorenal syndrome (P<0.001), and a history of obesity (P=0.004). Multivariate analysis showed that higher CTP score, ascitic fluid protein and prolonged QTc interval were independently associated with LVDD (P=0.009; P=0.018; P=0.016, respectively). Kaplan-Meier survival analysis showed significantly poorer survival status in patients with higher grades of LVDD (P<0.001). The area under the receiver operating characteristic curve (0.78) was greatest for ascitic fluid protein in predicting LVDD, with a cutoff of >1 g/dL.

Conclusions

Higher CTP score, prolonged QTc, higher ascitic fluid protein levels, and poor survival are significantly associated with LVDD. Ascitic fluid protein >1 g/dL could be an indicator for evaluating LVDD.

Early Risk Stratification for Natural Disease Course in Fabry Patients Using Plasma Globotriaosylsphingosine Levels

BACKGROUND

Fabry disease is a very heterogeneous X-linked lysosomal storage disease. Disease manifestations in the kidneys, heart, and brain vary greatly, even between patients of the same sex and with the same disease classification (classical or nonclassical). A biomarker with a strong association with the development of disease manifestations is needed to determine the need for Fabry-specific treatment and appropriate frequency of follow-up because clinical manifestations of the disorder may take decennia to develop.

METHODS

We investigated the levels of plasma lysoGb3 levels over time and its association with disease manifestations and disease course in 237 untreated patients with Fabry disease (median age 42 years, 38% male) using linear mixed-effect models.

RESULTS

LysoGb3 levels are stable over time in plasma of untreated patients with Fabry disease. Higher levels of lysoGb3 were associated with steeper decline in eGFR ( P = 0.05) and a faster increase in albuminuria (measured as the urinary albumin-to-creatinine ratio, P < 0.001), left ventricular mass (measured on echocardiography, P < 0.001), left atrial volume index ( P = 0.003), and Fazekas score ( P = 0.003). In addition, regardless of age, higher lysoGb3 levels were associated with higher relative wall thickness ( P < 0.001) and unfavorable functional markers on echocardiography, including septal mitral annular early diastolic velocity (e', P < 0.001) and the ratio of early transmitral velocity (E) to e' (E/e', P = 0.001).

CONCLUSIONS

In an individual patient with Fabry disease, the plasma lysoGb3 level reached a specific level in early childhood which, in the absence of Fabry-specific treatment, remained stable throughout life. The level of lysoGb3 in untreated patients was associated with nearly all Fabry-specific disease manifestations, regardless of the sex of the patient.

Clinicopathological Significance and Prognostic Role of Her2neu Protein Expression in Patients with Carcinoma Stomach: A Prospective Study from Northern India

Manas Kumar BeheraBackground and Aims  Gastric cancer is the third most common cause of cancer-related mortality worldwide after lungs and colorectum. Although controversial, Her2neu overexpression by immunohistochemistry is usually associated with poor prognosis in patients with carcinoma stomach. We conducted a prospective study to evaluate the prognostic role of Her2neu and its correlation with clinical, pathologic type, and stage of the disease. Methods  A prospective study was performed on paraffin blocks of 111 gastric cancer specimens (88 patients were biopsy specimens and 23 were gastrectomy specimens). The paraffin blocks were processed for Her2neu receptor immunohistochemical staining and fluorescence in situ hybridization, and scoring was done. Results  Her2neu overexpression was detected in 30 out of 111 (27%) patients. The mean age was 57.68 ± 12.82 years, with males constituting two-thirds of total patients. Tobacco addiction was found in 44% of the patients and smoking in 33% of the patients. Her2neu expression was similar in Lauren's intestinal and diffuse histologic type; however, proximal gastric tumors overexpressed Her2neu as compared with distal tumors. Her2neu 2+ or 3 + (odds ratio: 2.52, 95% CI: 1.61-3.95, p  = 0.001) was the only independent predictor of survival in gastric cancer patients. Kaplan-Meir survival analysis showed that the survival of gastric cancer patients with Her2neu overexpression (Her2neu 2+ or 3 + ) was significantly lower than that of those with Her2neu nonexpression ( p  = 0.001). Conclusion  Her2neu positivity was a significant predictor of mortality in patients with carcinoma stomach, and Her2neu overexpression was associated with a lower overall survival rate compared with Her2neu nonexpression.

HFA-PEFF score as an independent predictor of 2-year mortality in liver cirrhosis patients

BACKGROUND AND AIMS

Cardiovascular complications of liver cirrhosis include high cardiac output heart failure with reduced afterload and diastolic dysfunction. Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) (values 0-6) is a diagnostic tool for heart failure. It is a cluster of echocardiographic and biochemical parameters. The purpose of this prospective study was to assess if HFA-PEFF score is associated with the severity of liver disease and to determine its prognostic significance in patients with cirrhosis.

METHODS

Patients with cirrhosis without an acute event were enrolled. A comprehensive echocardiography study was conducted, brain natriuretic peptide and N-terminal-pro-B-type Natriuretic Peptide levels were measured and HFA-PEFF score was calculated. All patients were prospectively followed up after enrollment. The study end-point was defined as the composite of all-cause death.

RESULTS

Seventy-two consecutive patients [median age 59 years (inter-quartile range: 52-65), 72.2% males, Model for End-stage Liver Disease (MELD) 12.9 (8.5-16.3)] were included. The 52.8% had a high HFA-PEFF score (5 or 6) and the 47.2% intermediate/low score (0-4). HFA-PEFF score was correlated with MELD score (rho = 0.566, P  < 0.001), but not with age, SBP and heart rate. The median follow-up was 24.2 (9.5-38.8) months. The 1- and 2-year cumulative mortality was higher in patients with high HFA-PEFF compared to those with intermediate/low (log-rank P  < 0.001 for both). The predicted 2-year probability of survival in high vs intermediate/low HFA-PEFF was found to be a prognostic factor of death even when adjusted for age, gender and MELD score [hazard ratio = 3.539 (1.134-11.046), P  = 0.029].

CONCLUSION

HFA-PEFF score is high among patients with liver cirrhosis, especially those with advanced liver disease. HFA-PEFF score is associated with survival even when adjusting for cirrhosis severity.

Impact of previous cardiac function status assessed by echocardiography on the outcome of COVID-19

More than 91,000 fatalities due to Coronavirus Disease 2019 (COVID-19) have occurred in Spain. Several factors are associated with increased mortality in this disease, including cardiovascular risk factors (CVRF). However, information on the cardiac function of patients prior to the onset of COVID-19 is scarce and the potential impact it may have is uncertain. The aim of the EchoVID study was to describe the potential association between CVRF and cardiac function status prior to SARS-CoV-2 infection and in-hospital mortality. We studied clinical characteristics and cardiac function of patients admitted during the first wave of COVID-19. All patients had a transthoracic echocardiogram performed in the previous 12 months prior to diagnosis; conventional systolic and diastolic function parameters were analyzed. Logistic regression analysis was performed to identify predictors of in-hospital mortality. We included 296 individuals. Median age was higher in the group of patients who died (81.0 vs 76.1 years; p = 0.007). No significant differences were found in CVRF. Survivors were more frequently receiving anticoagulation therapy (52.9% vs 70.8%; p = 0.003). LVEF, although preserved on average in both groups, was significantly lower in the group of deceased patients (56.9% vs 61.1%; p = 0.017). Average E/e′ ratio was higher in the deceased group (11.1 vs 10.1; p = 0.049). Five variables were found to be independently associated with in-hospital mortality due to COVID-19: Age, male gender, LVEF, E/e′ ratio and anticoagulation therapy. A model including these variables had an area under the ROC curve of 0.756 (CI 0.669–0.843). The echocardiographic variables included in the model significantly improved the discriminative power, compared to a model including only demographic data. Left ventricular ejection fraction and E/e′ ratio prior to SARS-CoV-2 infection are two easily-obtained echocardiographic parameters that provide additional prognostic information over clinical factors when assessing patients admitted for SARS-CoV-2 infection.