Correlation Between Liver Stiffness and Diastolic Function, Left Ventricular Hypertrophy, and Right Cardiac Function in Patients With Ejection Fraction Preserved Heart Failure

Liver biomarkers as predictors of prognosis in heart failure with preserved ejection fraction: a systematic review and meta-analysis

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) accounts for 50% of heart failure cases, with increasing prevalence due to aging and risk factors such as hypertension and obesity. Liver dysfunction is common in HFpEF and may impact prognosis. This systematic review and meta-analysis aimed to evaluate the prognostic value of liver function markers (albumin, bilirubin, AST, ALT, ALP) in HFpEF patients.

METHODS

A systematic search of PubMed, Embase, Web of Science, and Scopus was conducted for studies assessing the association of liver markers with adverse outcomes in HFpEF. The primary outcome was a composite of heart failure-related hospitalization or death. Hazard ratios (HR) were pooled using a random-effects model, and heterogeneity was assessed using the I² statistic.

RESULTS

Twenty studies involving 30,623 patients were included. Serum albumin, the main marker of our study, was significantly associated with a reduced risk of adverse outcomes in a meta-analysis of 16 studies (HR 0.71, 95% CI: 0.61-0.83; I² = 87%). After excluding outliers, heterogeneity decreased (I² = 23%), and the association remained significant (HR 0.75, 95% CI: 0.69-0.82). Although no significant associations were found for AST, ALT, ALP, or bilirubin with adverse outcomes, the limited number of studies for these markers may have contributed to the lack of statistical significance.

CONCLUSION

Higher serum albumin levels predict better outcomes in HFpEF, while other liver function markers showed limited prognostic utility. Serum albumin may serve as a valuable marker for risk stratification in HFpEF.

Correlation of the FIB-4 Liver Biomarker Score with the Severity of Heart Failure

Background and Objectives: Heart failure is associated with high morbidity and mortality and linked with several pre-existing health conditions and risk factors. Early detection and prompt management in heart failure improves patient outcomes. Liver involvement is associated with heart failure disease progression, and hence liver biomarkers and liver fibrosis may have a prognostic impact. Several blood test based markers and scoring systems estimate liver fibrosis and hence can be useful prognostic tools. Materials and Methods: We retrospectively analyzed a series of 303 patients with decompensated heart failure in a city in western Romania over a period of 6 months. Several biochemical parameters were measured, the FIB-4 score was estimated and echocardiography was performed. Results for targeted variables are presented using descriptive statistics. Patients were analyzed based on their LVEF categories. Statistical analysis was based on ANOVA one-way tests for continuous variables and Chi-square tests for categorical variables. Pairwise comparisons were performed based on Bonferroni adjusted significance tests. The correlations between FIB-4 score, LVEF and NT-pro BNP in patients with and without diabetes and hypertension were explored using Spearman's correlation coefficient. Result: Age, gender, NYHA class, death, history of (h/o) type 2 diabetes mellitus (T2DM), h/o coronary artery disease (CAD), h/o arrhythmias, sodium, potassium, creatinine, eGFR, uric acid, NT-pro BNP, left atrial volume, LDL, HDL, and TG were analyzed by LVEF categories using ANOVA one-way tests, Chi-square tests, and Bonferroni correction comparisons. We found a strong statistically significant correlation between each of NT-pro BNP, left atrial volume, LDL, and HDL with the LVEF categories. Discussion: Early detection of cardiac dysfunction leads to better management in patients with cardiovascular risk factors including diabetes and hypertension. High LDL and low HDL levels contribute to a reduction in left ventricular (LV) function. Available literature suggests the FIB-4 score as superior to other non-invasive markers of fibrosis. It utilizes the patient's age, platelet count, AST, and ALT, which can be available retrospectively, making it an easy and inexpensive tool. FIB-4 score has a few limitations. Conclusions: Our study has shown a statistically significant positive correlation between severity categories of LVEF and FIB-4 score for heart failure patients with and without diabetes, and for heart failure patients with or without hypertension. We propose the implementation of FIB-4 score as a prognostic tool for heart failure.

The Assessment of Cardiovascular Abnormalities in Patients With Chronic Liver Disease: A Cross-Sectional Study

Background Chronic liver disease (CLD) is associated with a wide range of systemic complications, including cardiovascular abnormalities. This study aimed to assess the prevalence of cardiac abnormalities and to correlate with the severity of liver disorder. Materials and methods A cross-sectional analysis comprising 120 adult subjects diagnosed with CLD was performed. Data were collected through clinical assessments, including liver function tests, echocardiography, and electrocardiograms (ECG). The severity of CLD was determined using the Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scoring systems. Results In this study, 85 (70.8%) were men, and the major cause of CLD was alcoholism in 89 (66.7%) of the patients. Regarding CLD severity, the majority of patients were in MELD stage 2, and 70 (58.3%) and 76 (63.3%) were in CTP class C. The prevalence of various cardiac abnormalities was as follows: left ventricular systolic dysfunction (LVSD) in 25 (20.8%), left ventricular diastolic dysfunction (LVDD) in 76 (63.3%), and prolonged corrected QT (QTc) in 52 (43.3%) of the CLD patients. The values of the QTc interval were higher in MELD stage 3, and it was significant (p=0.001). The association between LVSD (p=0.004) and LVDD (p=0.001) was significant, and the proportion of CLD subjects with cardiac dysfunction was greater in CTP class C compared to classes B and A. Conclusion The present study highlights a concerning prevalence of cardiovascular abnormalities among chronic liver disease patients, underscoring the need for routine cardiovascular assessment in this population.

Liver stiffness is associated with right heart dysfunction, cardiohepatic syndrome, and prognosis in pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) can lead to congestive hepatopathy, known as cardiohepatic syndrome (CHS). Hepatic congestion is associated with increased liver stiffness, which can be quantified using shear wave elastography. We aimed to investigate whether hepatic shear wave elastography detects patients at risk in the early stages of PH.

METHODS

Sixty-three prospectively enrolled patients undergoing right heart catheterization (52 diagnosed with PH and 11 with invasive exclusion of PH) and 52 healthy volunteers underwent assessments including echocardiography and hepatic shear wave elastography. CHS was defined as increased levels of ≥2 of the following: gamma-glutamyl transferase, alkaline phosphatase, and bilirubin. Liver stiffness was defined as normal (≤5.0 kPa) or high (>5.0 kPa).

RESULTS

Compared with normal liver stiffness, high liver stiffness was associated with impaired right ventricular (RV) and right atrial (RA) function (median [interquartile range] RV ejection fraction: 54 [49; 57]% vs 45 [34; 51]%, p < 0.001; RA reservoir strain: 49 [41; 54]% vs 33 [22; 41]%, p < 0.001), more severe tricuspid insufficiency (p < 0.001), and higher prevalence of hepatovenous backflow (2% vs 29%, p < 0.001) and CHS (2% vs 10%, p = 0.038). In the patient subgroup with precapillary PH (n = 48), CHS and high liver stiffness were associated with increased European Society of Cardiology/European Respiratory Society 2022 risk scores (p = 0.003).

CONCLUSIONS

Shear wave liver elastography yields important information regarding right heart function and may complement risk assessment in patients with (suspected) PH.

HFpEF as systemic disease, insight from a diagnostic prediction model reminiscent of systemic inflammation and organ interaction in HFpEF patients

Systemic inflammation and reciprocal organ interactions are associated with the pathophysiology of heart failure with preserved ejection fraction (HFpEF). However, the clinical value, especially the diagnositc prediction power of inflammation and extra-cardiac organ dysfunction for HfpEF is not explored. In this cross-sectional study, 1808 hospitalized patients from January 2014 to June 2022 in ChiHFpEF cohort were totally enrolled according to inclusion and exclusion criteria. A diagnostic model with markers from routine blood test as well as liver and renal dysfunction for HFpEF was developed using data from ChiHFpEF-cohort by logistic regression and assessed by receiver operating characteristic curve (ROC) and Brier score. Then, the model was validated by the tenfold cross-validation and presented as nomogram and a web-based online risk calculator as well. Multivariate and LASSO regression analysis revealed that age, hemoglobin, neutrophil to lymphocyte ratio, AST/ALT ratio, creatinine, uric acid, atrial fibrillation, and pulmonary hypertension were associated with HFpEF. The predictive model exhibited reasonably accurate discrimination (ROC, 0.753, 95% CI 0.732-0.772) and calibration (Brier score was 0.200). Subsequent internal validation showed good discrimination and calibration (AUC = 0.750, Brier score was 0.202). In additoin to participating in pathophysiology of HFpEF, inflammation and multi-organ interactions have diagnostic prediction value for HFpEF. Screening and optimizing biomarkers of inflammation and multi-organ interactions stand for a new field to improve noninvasive diagnostic tool for HFpEF.

Beta-blockers in Hypertensive Left Ventricular Hypertrophy and Atrial Fibrillation Prevention

BACKGROUND

Hypertensive left ventricular hypertrophy (HTN LVH) is a key risk factor for atrial fibrillation (AF).

OBJECTIVE

To evaluate the possible role of beta-blockers (BBs) in addition to a renin-angiotensinaldosterone system (RAAS) blocker in AF prevention in patients with HTN LVH.

METHODS

We performed a PubMed, Elsevier, SAGE, Oxford, and Google Scholar search with the search items 'beta blocker hypertension left ventricular hypertrophy patient' from 2013-2023. In the end, a 'snowball search', based on the references of relevant papers as well as from papers that cited them was performed.

RESULTS

HTN LVH is a risk factor for AF. In turn, AF substantially complicates HTN LVH and contributes to the genesis of heart failure (HF) with preserved ejection fraction (HFpEF). The prognosis of HFpEF is comparable with that of HF with reduced EF (HFrEF), and, regardless of the type, HF is associated with five-year mortality of 50-75%. The antiarrhythmic properties of BBs are wellrecognized, and BBs as a class of drugs are - in general - recommended to decrease the incidence of AF in HTN.

CONCLUSION

BBs are recommended (as a class) for AF prevention in several contemporary guidelines for HTN. LVH regression in HTN - used as a single criterion for the choice of antihypertensive medication - does not capture this protective effect. Consequently, it is worth studying how meaningful this antiarrhythmic action (to prevent AF) of BBs is in patients with HTN LVH in addition to a RAAS blocker.

The Liver in Heart Failure: From Biomarkers to Clinical Risk

Heart failure (HF) is a clinical syndrome due to heart dysfunction, but in which other organs are also involved, resulting in a complex multisystemic disease, burdened with high mortality and morbidity. This article focuses on the mutual relationship between the heart and liver in HF patients. Any cause of right heart failure can cause hepatic congestion, with important prognostic significance. We have analyzed the pathophysiology underlying this double interaction. Moreover, we have explored several biomarkers and non-invasive tests (i.e., liver stiffness measurement, LSM) potentially able to provide important support in the management of this complex disease. Cardiac biomarkers have been studied extensively in cardiology as a non-invasive diagnostic and monitoring tool for HF. However, their usefulness in assessing liver congestion in HF patients is still being researched. On the other hand, several prognostic scores based on liver biomarkers in patients with HF have been proposed in recent years, recognizing the important burden that liver involvement has in HF. We also discuss the usefulness of a liver stiffness measurement (LSM), which has been recently proposed as a reliable and non-invasive method for assessing liver congestion in HF patients, with therapeutic and prognostic intentions. Lastly, the relationship between LSM and biomarkers of liver congestion is not clearly defined; more research is necessary to establish the clinical value of biomarkers in assessing liver congestion in HF patients and their relationship with LSM.

Liver stiffness is associated with excess mortality in the general population driven by heart failure: The Rotterdam Study

BACKGROUND

Elevated liver stiffness reflects hepatic fibrosis but can also be secondary to venous congestion. We aimed to study the association between liver stiffness and mortality in the general population, stratified for heart failure and/or coronary heart disease (CHD).

METHODS

We analysed individuals enrolled in the ongoing prospective population-based Rotterdam Study who attended a visit between 2009-2014 that included liver stiffness measurement. Exclusion criteria for the primary analysis were incomplete data on heart failure, unreliable liver stiffness, alcohol abuse and viral hepatitis, leaving 4.153 participants (aged 67.5 ± 8.4 years, 44.2% male) for analysis with a median follow-up of 6.0 (interquartile range: 5.1-7.0) years. Secondary analysis included participants with viral hepatitis, alcohol abuse and/or unreliable measurement. The association between liver stiffness and mortality was assessed using Cox regression. Associations between heart failure, CHD, and echocardiographic characteristics and liver stiffness were quantified with linear regression.

RESULTS

Liver stiffness ≥8.0 kPa was associated with mortality (aHR: 1.37, 95%CI: 1.00-1.89). However, this was driven by participants with heart failure (aHR: 2.48, 95%CI: 1.15-5.35), since high liver stiffness was not associated with mortality in participants without heart failure and/or CHD (aHR: 1.07, 95%CI: 0.70-1.64). Results were consistent when individuals with viral hepatitis, alcohol abuse or unreliable liver stiffness measurement were not excluded. Several cardiovascular characteristics were significantly associated with higher liver stiffness, e.g. heart failure, moderate/poor diastolic dysfunction, and right atrium diameter > 4.5 cm.

CONCLUSION

In our cohort of community-dwelling elderly, high liver stiffness was associated with excess mortality, primarily explained by participants with heart failure. Moreover, heart failure and its indicators were associated with increased liver stiffness.