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Ostojic A, Mahmud N, Reddy KR. Surgical risk stratification in patients with cirrhosis. Hepatol Int 2024; 18:876-891. [PMID: 38472607 DOI: 10.1007/s12072-024-10644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024]
Abstract
Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.
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Affiliation(s)
- Ana Ostojic
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb, Kispaticeva 12, Zagreb, 10000, Croatia
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, HUP, Philadelphia, PA, 19104, USA.
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Khandait H, Jaiswal V, Hanif M, Shrestha AB, Iturburu A, Shah M, Ishak A, Garimella V, Ang SP, Mathew M. Percutaneous Coronary Intervention Outcomes in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10030092. [PMID: 36975856 PMCID: PMC10059068 DOI: 10.3390/jcdd10030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/01/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
There is a paucity of data and minimal literature on outcomes of percutaneous coronary intervention (PCI) among liver cirrhosis patients. Therefore, we conducted a systematic review and meta-analysis to evaluate the clinical outcomes among liver cirrhosis patients post-PCI. We conducted a comprehensive literature search in the PubMed, Embase, Cochrane, and Scopus databases for relevant studies. Effect sizes were pooled using the DerSimonian and Laird random-effects model as an odds ratio (OR) with 95% confidence intervals (CI). A total of 3 studies met the inclusion criteria, providing data from 10,705,976 patients. A total of 28,100 patients were in the PCI + Cirrhosis group and 10,677,876 patients were in the PCI-only group. The mean age of patients with PCI + Cirrhosis and PCI alone was 63.45 and 64.35 years. The most common comorbidity was hypertension among the PCI + Cirrhosis group compared with PCI alone (68.15% vs. 73.6%). Cirrhosis patients post-PCI were had higher rates of in-hospital mortality (OR, 4.78 (95%CI: 3.39–6.75), p < 0.001), GI bleeding (OR, 1.91 (95%CI:1.83–1.99), p < 0.001, I2 = 0%), stroke (OR, 2.48 (95%CI:1.68–3.66), p < 0.001), AKI (OR, 3.66 (95%CI: 2.33–6.02), p < 0.001), and vascular complications (OR, 1.50 (95%CI: 1.13–1.98), p < 0.001) compared with the PCI group without cirrhosis. Patients with cirrhosis are at a high risk for mortality and adverse outcomes post-PCI procedure compared to the PCI-only group of patients.
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Affiliation(s)
| | - Vikash Jaiswal
- Department of Research, JCCR Cardiology Research, Varanasi 221005, India
- Correspondence:
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | | | - Alisson Iturburu
- Department of Medicine, Universidad de Guayaquil, Guayas 090514, Ecuador
| | - Maitri Shah
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Angela Ishak
- Department of Research and Academic Affairs, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Vamsi Garimella
- Department of Internal Medicine, University of Miami (Holy Cross), Miami, FL 33136, USA
| | - Song Peng Ang
- Division of Internal Medicine, Rutgers Health/Community Medical Center, Toms River, NJ 08755, USA
| | - Midhun Mathew
- Trinitas Regional Medical Center/RWJ Barnabas Health, Elizabeth, NJ 07202, USA
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Ma J, Chalasani NP, Schwantes-An L, Björnsson ES. Review article: the safety of anticoagulants and antiplatelet agents in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:52-71. [PMID: 36373544 DOI: 10.1111/apt.17297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
Patients with cirrhosis were long thought to be coagulopathic. However, this paradigm has changed in recent years and currently, cirrhosis is recognised as a prothrombotic state. Due to the increasing incidence of cirrhosis from nonalcoholic steatohepatitis which is closely associated with cardiac disease, patients with cirrhosis increasingly require therapy with anticoagulants and antiplatelet agents. However, their potential for causing catastrophic and life-threatening bleeding in patients with cirrhosis leads to hesitancy about their use in patients with cirrhosis. Overall, traditional anticoagulation is safe for all Child-Pugh classes while newer direct oral anticoagulants (DOACs) are mostly safe in Child-Pugh class A/B and contraindicated in severe hepatic impairment. For different indications, published data to date suggest that anticoagulation is overall safe for patients with cirrhosis who have venous thromboembolism, atrial fibrillation and portal vein thrombosis, and does not increase the risk of variceal bleeding. Moreover, DOACs appear to have similar safety profiles as traditional anticoagulants. Finally, most studies suggest that antiplatelet agents are also safe to use in patients with cirrhosis although they are mostly contraindicated in severe hepatic impairment. For both anticoagulants and antiplatelet agents, severe thrombocytopaenia presents a relative contraindication to their use. More prospective trials and large cohort studies are needed to advance our understanding of the safety and nuances of DOACs and antiplatelet agents in patients with advanced cirrhosis.
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Affiliation(s)
- Jiayi Ma
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Linus Schwantes-An
- Indiana University School of Medicine, Medical & Molecular Genetics, Indianapolis, Indiana, USA
| | - Einar Stefán Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Kozlik A, Wiseman K, Upadhyaya VD, Sharma A, Chatterjee S. Preoperative Coronary Intervention Before Orthotopic Liver Transplantation (from a Review of Literature). Am J Cardiol 2022; 185:94-99. [DOI: 10.1016/j.amjcard.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
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Gîrleanu I, Trifan A, Huiban L, Muzîca C, Petrea OC, Sîngeap AM, Cojocariu C, Chiriac S, Cuciureanu T, Costache II, Stanciu C. Ischemic Heart Disease and Liver Cirrhosis: Adding Insult to Injury. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071036. [PMID: 35888123 PMCID: PMC9315506 DOI: 10.3390/life12071036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Irina Gîrleanu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Anca Trifan
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
- Correspondence: ; Tel.: +40-762278575
| | - Laura Huiban
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Cristina Muzîca
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Oana Cristina Petrea
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Ana Maria Sîngeap
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Camelia Cojocariu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Stefan Chiriac
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Tudor Cuciureanu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Irina Iuliana Costache
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Cardiology Department, Saint Spiridon University Hospital, 700115 Iaşi, Romania
| | - Carol Stanciu
- Depatment of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iaşi, Romania; (I.G.); (L.H.); (C.M.); (O.C.P.); (A.M.S.); (C.C.); (S.C.); (T.C.); (I.I.C.); (C.S.)
- Institute of Gastroenterology and Hepatology, Saint Spiridon University Hospital, 700115 Iaşi, Romania
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