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Cardiovascular complications of
cirrhosis
S Mller, J H Henriksen
Department of Clinical ABSTRACT discussion.4 This review will primarily centre on
Physiology 239, Hvidovre Cardiovascular complications of cirrhosis include cardiac clinical and pathophysiological aspects of the
Hospital, University of
dysfunction and abnormalities in the central, splanchnic circulatory and cardiac complications of advanced
Copenhagen, Copenhagen,
Denmark and peripheral circulation, and haemodynamic changes cirrhosis.
caused by humoral and nervous dysregulation. Cirrhotic
Correspondence to: cardiomyopathy implies systolic and diastolic dysfunction
Associate Professor S Mller, and electrophysiological abnormalities, an entity that is THE CIRCULATION IN CIRRHOSIS
Department of Clinical An increase in cardiac output can be attributed to
Physiology, 239, Hvidovre different from alcoholic heart muscle disease. Being
Hospital, DK-2650 Copenhagen, clinically latent, cirrhotic cardiomyopathy can be an increase in venous return, heart rate and
Denmark; soeren.moeller@ unmasked by physical or pharmacological strain. myocardial contractility, all of which are controlled
hvh.regionh.dk
Consequently, caution should be exercised in the case of by the autonomic nervous system. Vasodilatation
stressful procedures, such as large volume paracentesis (low systemic vascular resistance), the presence of
Revised 2 August 2007 arteriovenous communications, expanded blood
Accepted 2 August 2007 without adequate plasma volume expansion, transjugular
intrahepatic portosystemic shunt (TIPS) insertion, perito- volume and increased sympathetic nervous activity
neovenous shunting and surgery. Cardiac failure is an may further raise the cardiac output; most of these
important cause of mortality after liver transplantation, but pathophysiological mechanisms are active in
improved liver function has also been shown to reverse advanced cirrhosis.1 2 In the early stages, the
the cardiac abnormalities. No specific treatment can be presence of a hyperdynamic circulation is often
recommended, and cardiac failure should be treated as in not apparent. However, with the progression of
non-cirrhotic patients with sodium restriction, diuretics, the liver disease, there is an overall association
and oxygen therapy when necessary. Special care should between the severity of the cirrhosis and the degree
be taken with the use of ACE inhibitors and angiotensin of hyperdynamic circulation. Studies on circulatory
antagonists in these patients. The clinical significance of changes with posture suggest that the patients are
cardiovascular complications and cirrhotic cardiomyopathy mostly hyperdynamic in the supine position.3 5 6
is an important topic for future research, and the initiation Blood and plasma volumes are raised in advanced
of new randomised studies of potential treatments for cirrhosis, but the distribution between central and
these complications is needed. non-central vascular areas is unequal.7 8 Thus, by
different techniques it has been established that
the central and arterial blood volumethat is, the
The course in most cirrhotic patients is dominated blood volume in the heart, lungs and central
by complications to portal hypertension, such as arterial treeis most often decreased, whereas
bleeding from oesophageal varices and ascites with the non-central blood volume, in particular the
the development of spontaneous bacterial perito- splanchnic blood volume, is increased in animals
nitis, renal impairment and encephalopathy. Some and patients with cirrhosis (see table 1).2 7 9 10 The
patients, however, seem to die of causes unrelated effective arterial blood volume (ie, the circulatory
to these complications. A closer clinical look shows compartment sensed by baroreceptors) and the
that a number of these patients display signs of central circulation time (ie, central blood volume
cardiovascular disturbances secondary to vasodila- relative to cardiac output) are substantially
tation, with palmar erythema and reddish skin, reduced and bear a significant relationship to
raised and bounding pulse, and a low systemic poorer survival in advanced cirrhosis.11
blood pressure indicating a hyperdynamic circula- Total vascular compliance as well as arterial
tion.1 2 The hyperdynamic syndrome was first compliance (ie, an increase in intravascular volume
described .50 years ago and comprises increased relative to an increase in transmural blood pres-
heart rate, cardiac output and plasma volume, and sure) are increased in cirrhosis with the degree of
reduced systemic vascular resistance and arterial decompensation.12 13 The altered static and
blood pressure.13 The hyperdynamic syndrome is dynamic characteristics of the wall of large arteries
today a well-characterised element in the clinical are closely associated with the circulatory and
appearance of the cardiovascular complications of homoeostatic derangement.7 13 14 Arterial compli-
cirrhosis and portal hypertension of various aetiol- ance depends on the properties of the elastic and
ogies.1 2 Experimental and clinical findings of smooth muscle of the arterial wall and represents
impaired cardiac function have led to the introduc- an important coupling between the heart and the
tion of the new clinical entity, cirrhotic cardiomyo- arterial system with respect to relocation of
pathy, but cardiac dysfunction is not seen in all intravascular volume.14 The changes in arterial
patients, especially not in those with less advanced mechanics are reversible at least in part.13 An
disease, and its clinical significance is still under element in the elevated arterial compliance in
Table 1 Circulatory changes in specific vascular beds in an integral variable for vascular responsiveness,
cirrhosis together with the systemic vascular resistance.
Arterial compliance is easy to determine and
Systemic circulation
elevated in advanced cirrhosis. Besides a relation-
Plasma volume q
ship to age, body size, sex and the level of arterial
Total blood volume q
Non-central blood volume q
blood pressure, arterial compliance is directly
Central and arterial blood volume Q (R)
related to the severity of cirrhosis, the hyperdy-
Arterial blood pressure Q (R) namic circulatory derangement and abnormal
Systemic vascular resistance Q volume distribution. Its role in clinical hepatology,
Cutaneous and skeletal muscle circulation however, remains to be established.
Skeletal muscular blood flow* q R Q The pulmonary vascular resistance is often
Cutaneous blood flow* q R Q decreased in cirrhosis, except in the 24% of the
Heart patients with portopulmonary hypertension.16
Heart rate q Some patients exhibit characteristic vascular
Cardiac output q abnormalities with arteriovenous shunts and
Left atrial volume q intrapulmonary dilatations.1 16 Ventilatory lung
Left ventricular volume R (q) function and diffusion are impaired in the majority
Right atrial volume R q Q of the patients, and the combination of vascular
Right atrial pressure R q abnormalities, reduced transfer factor and low
Right ventricular end-diastolic pressure R arterial oxygen saturation has been termed the
Pulmonary artery pressure R q hepatopulmonary syndrome.16 In patients with
Pulmonary capillary wedge pressure R cirrhosis, the reduced transfer factor correlates
Left ventricular end-diastolic pressure R
with the low pulmonary blood volume, which
Total vascular compliance q
suggests that central underfilling also plays a role
Arterial compliance q
in the impairment of pulmonary function.17
Hepatic and splanchnic circulation
Hepatic blood flow{ Q R (q)
Hepatic venous pressure gradient q Pathophysiology of splanchnic arteriolar
Postsinusoidal resistance q vasodilatation
Renal circulation Arteriolar vasodilatation in cirrhosis and portal
Renal blood flow Q hypertension may be brought about by a combina-
Glomerular filtration rate (q)Q R tion of overproduction of circulating vasodilators,
Cerebral circulation vasodilators of intestinal or systemic origin, vaso-
Cerebral blood flow QR dilators that escape degradation in the diseased
Pulmonary circulation liver or bypass the liver through portosystemic
Pulmonary blood flow q collaterals, reduced resistance to vasoconstrictors
Pulmonary vascular resistance Q (q{) and increased sensitivity to vasodilators.1 2
Pulmonary blood volume Q
According to the arterial vasodilation hypoth-
Pulmonary transit time Q
esis, splanchnic arteriolar vasodilation leads to
q R Q denote: increased, unchanged and decreased, respectively. reduction of the systemic vascular resistance,
Arrows in parentheses describe early/less typical changes.
*Available data are highly dependent on the applied technique. central arterial underfilling with effective hypovo-
{Changes in intrahepatic blood flow due to variable co-determination of laemia, activation of vasoconstrictor systems, such
portosystemic shunts.
{Increased in portopulmonary hypertension.
as the sympathetic nervous system (SNS), the
reninangiotensinaldosterone system (RAAS),
vasopressin, endothelins (ETs) and neuropeptide
advanced cirrhosis is the reduced arterial blood Y, and hence development of a hyperkinetic
volume and blood pressure.7 Arterial compliance circulatory state.1 8 18 Thus, most of the haemody-
expresses the stroke volume relative to the pulse namic changes summarised in table 1 and figure 1
pressure and is directly related to the severity of can be explained by this theory. The predomi-
cirrhosis.13 14 However, in contrast to the systemic nantly splanchnic vasodilation in cirrhosis precedes
vascular resistance, arterial compliance may be the increase in cardiac output and heart rate, and it
determined independently of flow and pressure by has recently been shown experimentally that mild
pulsewave velocity.14 In addition, the arterial increases in portal pressure upregulate nitric oxide
compliance in cirrhosis seems to be affected by synthase (eNOS).19 With the progression of the
vasoactive forces as it correlates directly with the disease, the splanchnic vasodilatation becomes
vasodilator calcitonin gene-related peptide (CGRP) more pronounced and the hyperdynamic circula-
and inversely with catecholamines.13 The arteriolar tion may no longer be sufficient to correct the
tone adjusts the level of the blood pressure and effective hypovolaemia.20 21 The splanchnic circula-
may thereby influences large artery compliance. tion is less sensitive to the effects of angiotensin II,
Recent data suggest that the hyperdynamic circu- noradrenaline and vasopressin because of the
lation is mainly caused by circulatory alterations in surplus of vasodilators which may play a role in
the splanchnic area.15 Thus, arteriolar vasodilata- the development of the vascular hyporesponsive-
tion would be a more localised event, whereas the ness to vasoconstrictors.22 The arterial blood
elevation in arterial compliance may be more pressure is mainly maintained by vasoconstriction
systemic.7 Arterial compliance may therefore be in the renal, cerebral and hepatic vascular beds
Figure 1 Splanchnic and peripheral arteriolar vasodilation with reduced systemic and splanchnic vascular resistance leads to a reduced effective
arterial blood volume (CBV), and hence to activation of vasoconstrictor systems. The haemodynamic and clinical consequences are increases in portal
pressure (HVPG), cardiac output (CO), heart rate (HR), and plasma (PV) and blood volumes (BV), and increased renal vascular resistance (RVR) and
decreased renal blood flow (RBF), low systemic vascular resistance (SVR) and arterial blood pressure (MAP), and fluid and water retention. The
development of the hyperdynamic circulation may increase portal inflow and further aggravate portal hypertension in a vicious cycle. SNS, sympathetic
nervous system; RAAS, reninangiotensinaldosterone system; AVP, arginine vasopressin; ET, endothelin.
Table 2 Potential vasodilating and vasoconstricting nitrates, octreotide, terlipressin, etc. can reduce the
forces involved in disturbed haemodynamics in cirrhosis increased splanchnic blood flow pharmacologically,
(alphabetic order). Substances mentioned in the text are and infusion of these drugs may in some patients
written in italics partially reverse the hyperkinetic mesenteric circu-
Vasodilator systems
lation. As outlined above, there seems to be a
Adenosine defective sinusoidal eNOS-derived production of
Adrenomedullin NO.15 In addition, recent investigations of endo-
Atrial natriuretic peptide (ANP) genous vasoactive substances have focused espe-
Bradykinin cially on ET-1, angiotensin II, catecholamines and
Brain natriuretic peptide (BNP) leukotrienes in the increased hepaticsinusoidal
Calcitonin gene-related peptide (CGRP) resistance.1 30 The haemodynamic imbalance with
Carbon monoxide (CO) a predominant sinusoidal constriction may con-
Endocannabinoids tribute significantly to the development of portal
Endothelin-3 (ET-3) hypertension and be an important target for
Endotoxin treatment.
Enkephalins
Glucagon
Volume distribution and circulatory dysfunction
Histamine
Hydrogen sulphide
Imbalance between vasodilating and vasoconstrict-
Interleukins
ing forces in cirrhosis contributes to an abnormal
Natriuretic peptide of type C (CNP) distribution of volume, vascular resistance and
Nitric oxide (NO) flow. Although the cardiac output is increased,
Prostacyclin (PGI2) thereby reflecting substantial vasodilatation, it
Substance P covers hyperperfused, normoperfused and hypo-
Tumour necrosis factor-a (TNF-a) perfused vascular beds. Thus, in the kidney,
Vasoactive intestinal polypeptide (VIP) vasoconstriction prevails and plays a pivotal role
Vasoconstrictor systems along with the development of hepatic decom-
Angiotensin II pensation. Liver dysfunction, central hypovolae-
Adrenaline and noradrenaline mia, arterial hypotension and neurohumoral
Sympathetic nervous system (SNS) activation of particularly the RAAS and SNS with
Endothelin-1 (ET-1) renal vasoconstriction is of major importance.1 20
Neuropeptide Y The increased plasma volume in cirrhosis should
Reninangiotensinaldosterone system (RAAS)/ therefore be considered secondary to the activation
Vasopressin (ADH) of neurohumoral mechanisms consequent on
mainly splanchnic vasodilatation, low arterial
blood pressure and reduced central and arterial
flow, but patients with portal hypertension have a
blood volume.
substantial portosystemic collateral circulation,
Central hypovolaemia and arterial hypotension
and an increased mesenteric inflow of up to several
may be ameliorated by infusion of plasma expan-
litres per minute has been reported (table 1). Thus,
ders. During volume expansion, most cirrhotic
a large part of the increased cardiac output is
patients respond with a further reduction in
returned through portosystemic collaterals. The
systemic vascular resistance rather than an increase
azygous blood flow is especially important, as the
in arterial blood pressure.7 9 The infusion of
azygous vein drains oesophageal varices and an
hyperosmotic solutions or albumin in cirrhosis
increase in azygous flow is associated with an
results initially in a shift of fluid from the
increased risk of variceal bleeding.11 b-Blockers,
interstitial space into the plasma volume, with
expansion of the latter.7 9 Irrespective of severity,
Table 3 Possible pathophysiological components in the volume expansion produces a rise in stroke volume
hyperdynamic circulation and cardiovascular dysfunction and cardiac output. In early cirrhosis there is a
in cirrhosis proportional expansion of the central and non-
Peripheral and splanchnic arterial vasodilatation central parts of the blood volume, whereas in late
Baroreceptor-induced increase in heart rate cirrhosis, expansion is mainly confined to the non-
Autonomic dysfunction central part, with a proportionally smaller increase
Increased sympathetic nervous activity in cardiac output, probably because of cardiac
Vagal impairment dysfunction and abnormal vascular compliance.9 31
Alterations in cardiac preload Similar effects are seen after infusion of a plasma
Increased portosystemic shunting protein solution, whereas infusion of packed red
Increased blood volume blood cells may be less efficient possibly because of
Effects of posture a difference in the trapping of NO and shear stress.1
Decreased blood viscosity When therapeutic paracentesis is done in decom-
Alterations in oxygen exchange
pensated cirrhosis without administration of
Anaemia
plasma expanders, about 75% of patients will
Hypoxaemia
develop what is termed paracentesis-induced cir-
Hepatopulmonary syndrome
culatory dysfunction.32 This condition is charac-
Portopulmonary hypertension
terised by a pronounced activation of the RAAS
and SNS, which reflects central hypovolaemia. It is Evaluation of brachial and femoral artery blood
mainly caused by a paracentesis-induced splanch- flow by Doppler techniques has failed to disclose a
nic arteriolar vasodilatation and brings about a clear hyperdynamic perfusion of the limbs.38 39
further reduction in the systemic vascular resis- Recently, however, it has been shown that block-
tance.33 Intravenous infusion of albumin has been ade of NOS causes peripheral vasoconstriction in
shown to prevent complications caused by circu- the forearm in cirrhosis and that this system
latory dysfunction and may prevent development contributes in the regulation of the peripheral
of renal failure and rapid occurrence of ascites, and vascular tone and to the hyperdynamic state.25
prolong survival.32 Recent studies have shown, Estimates of skin blood flow by nuclear medicine
however, that administration of vasoconstrictors techniques have shown normal capillary skin blood
such as terlipressin or noradrenaline may be flow in cirrhotic patients.40
effective alone or especially in combination with The techniques used are hampered by various
albumin.34 35 Paracentesis-induced circulatory dys- caveats relating to the methods in use and
function is thus an example of a cirrhotic condition experimental circumstances. Venous occlusion
where complications attributable to a potentially plethysmography with forearm and leg measure-
reduced effective blood volume can be prevented ments may give a combination of cutaneous and
by a specific volume expansion. muscular blood flow, but this method has also
The deterioration of the liver function is given identical baseline values in patients and
followed by a decreased renal blood flow and controls.41 We still have only a faint impression of
glomerular filtration rate, and increased sodium the haemodynamics of the peripheral circulation in
and water reabsorption, and may progress into the cirrhosis, and the cutaneous and muscular circula-
hepatorenal syndrome, a functional and reversible tions in cirrhosis are important topics for further
renal impairment in severely ill patients (table 1).20 research. At present it can be concluded that the
However, glomerular hyperfiltration has been increased cardiac output in patients with cirrhosis
described in some patients with preascitic cirrho- covers systemic vascular beds with various degrees
sis.36 Recently, a new concept has been put forward of perfusion, owing to an imbalanced state of
in the pathophysiological explanation of renal vasoconstriction and vasodilatation. The exact
dysfunction as a circulatory dysfunction charac- distribution of the increased cardiac output to the
terised by insufficient cardiac output leading to different organs, tissues and types of vessels
effective hypovolaemia.20 21 This concept is sup- remains to be clarified.
ported by data from a longitudinal study in non-
azotaemic cirrhotic patients suggesting that circu- ABNORMALITIES IN THE REGULATION OF THE
latory dysfunction with a decrease in cardiac CIRCULATION
output combined with splanchnic arterial vasodi- Autonomic dysfunction
latation and activation of the RAAS contribute to Cirrhosis is often associated with autonomic
renal dysfunction and the hepatorenal syn- neuropathy which has become evident from
drome.20 37 Angiotensin II mainly acts on the studies of haemodynamic responses to standard
efferent arteriole, and a low dose of an ACE cardiovascular reflex tests, such as heart rate
inhibitor may induce a significant reduction in variability and isometric exercise.3 5 42 Most studies
glomerular filtration and a further reduction in on these issues have found a high prevalence of
sodium excretion, even in the absence of a change autonomic dysfunction in cirrhosis with associa-
in arterial blood pressure. This suggests that the tions with liver dysfunction and survival.43 44 The
integrity of the RAAS is important for the autonomic dysfunction may be temporary, arises
maintenance of renal function in cirrhotic patients as a consequence of liver dysfunction and seems
and that RAAS overactivity does not solely reversible after liver transplantation.45 Most studies
contribute to the adverse renal vasoconstriction. have focused on defects in the SNS, but the
Treatment of the hepatorenal syndrome is directed importance of vagal impairment for sodium and
towards improving liver function by liver trans- fluid retention has been shown.3 42 43 Sympathetic
plantation, arterial hypotension and central hypo- responses to exercise are clearly impaired.46 47
volaemia, and reducing renal vasoconstriction, for Similarly, blood pressure responses to orthostasis
instance with the combined use of splanchnic are impaired, probably because of a blunted
vasoconstrictors such as terlipressin and plasma baroreflex function in advanced cirrhosis.5 48
expanders such as human albumin.20 Abnormal cardiovascular responses to vasocon-
strictors have been reported in patients with
The circulation of the extremities cirrhosis,1 and there is experimental evidence that
The cutaneous and muscular circulations may be haem oxygenase mediates hyporeactivity to phe-
increased in patients with cirrhosis.1 Palmar nylephrine in the mesenteric vessels of cirrhotic
erythema, spider naevi and potatory face were rats with ascites.27 Administration of captopril
early recognised as clinical signs of cutaneous partly corrects the parasympathetic dysfunction
hyperperfusion. These types of circulatory in cirrhosis, which indicates that the vagal compo-
abnormalities illustrate capillary hyperperfusion nent is to a certain extent caused by neuromodula-
and the presence of arteriovenous fistulae. tion with angiotensin II.43 Involvement of the
Muscular circulation is reported to be increased, RAAS is also supported by data that show
normal and reduced in patients with cirrhosis.38 39 normalisation of cardiac responses to postural
cirrhotic cardiomyopathy include impaired cardiac pulmonary capillary wedge pressure, with no
contractility with a systolic dysfunction, diastolic change in cardiac output.31 Recently, we have
dysfunction and electromechanical abnormalities shown by myocardial perfusion imaging that
with a prolonged QT interval.4 59 Various electro- infusion of terlipressin suppresses myocardial
physiological mechanisms for the conductance function, whereas the myocardial perfusion is left
abnormalities and impaired cardiac contractility unaffected.64 This response may be useful in
have been suggested and include changes in the diagnosing cirrhotic cardiomyopathy. A similar
cardiomyocyte plasma membrane with an pattern is seen after insertion of a transjugular
increased cholesterol/phospholipid ratio, attenu- intrahepatic portosystemic shunt (TIPS), but the
ated function of the b-adrenergic pathway and raised cardiac pressures after TIPS tend to normal-
greater activity of inhibitory systems.4 Other ise with time.65 66 Some of these patients (12%)
studies have focused on negative inotropic effects may develop manifest cardiac failure in association
of NO, nitration of cardiac proteins, CO, endogen- with the TIPS insertion.67 Similar effects are seen
ous cannabinoids, bile acids, endotoxins and other after infusion of plasma expanders. Infusion of a
systems.59 60 Cannabinoids are endogenous ligands plasma protein solution, however, increases cardiac
including anandamide that binds to cannabinoid output, as well as right atrial pressure, pulmonary
receptors CB1 and CB2.4 51 The production may arterial pressure and pulmonary capillary wedge
increase in response to stress such as tachycardia pressure, whereas infusion of packed red blood cells
and overload.61 Experimental studies have shown a may not produce a change in these variables.1
negative inotropic effect of anadamide in cirrhotic The LVEF reflects systolic function, even though
rats, which suggests that this system is involved in it is very much influenced by preload and afterload.
cirrhotic cardiomyopathy.4 62 The haem oxyge- It has been reported to be normal at rest in some
naseCO pathway has also been shown to play a studies and reduced in one study of a subgroup of
role in the pathogenesis of abnormal cardiac patients with ascites.31 63 68 After exercise, LVEF
contractility in cirrhotic cardiomyopathy.4 27 increases less in cirrhotic patients than in controls
(fig 3).59 63 69 The reduced functional capacity may
Systolic dysfunction be attributed to a combination of blunted heart
In cirrhotic cardiomyopathy, the left ventricular rate response to exercise, reduced myocardial
end-diastolic pressure increases after exercise, but reserve and profound skeletal muscle wasting with
the expected increases in cardiac stroke index and impaired oxygen extraction.46 47 In patients with
left ventricular ejection fraction (LVEF) are absent advanced cirrhosis and severe vasodilatation, acti-
or subnormal, which indicates an inadequate vation of the RAAS, impaired renal function and a
response of the ventricular reserve to a rise in reduced systolic function (a decrease in cardiac
ventricular filling pressure.63 A vasoconstrictor- output) appear to be major determinants for the
induced increase of 30% in the left ventricular development of the hepatorenal syndrome.37
afterload results in an approximate doubling in Spontaneous bacterial peritonitis is a well-known
Table 5 Diagnostic tools in the assessment of systolic Box 1: Key points of cirrhotic cardiomyopathy
and diastolic dysfunction
Systolic function
c Present in the face of a hyperkinetic circulation
c Echocardiography/MRI:
with a combined systolic and diastolic
c Volumes
dysfunction together with electrophysiological
c Fractional shortening
abnormalities.
c Velocity of fractional shortening
c Ejection fraction (planimetry)
c Different from alcoholic heart muscle disease
c Response to stress (dobutamine)
c Systolic dysfunction demasked by physical or
c Wall motion
pharmacological stress
c Exercise ECG: c Diastolic dysfunction detected by
c Exercise capacity echocardiographic measurement of the E/A ratio
c Oxygen consumption* c QT interval prolongation assessed on the ECG
c Pressure6heart rate product and adjusted adequately
c Radionuclide angiography (MUGA): c Treatment is non-specific and directed towards
c Ejection fraction the left ventricular heart failure
c Cardiac volumes
c Pattern of contractility
c Myocardial perfusion imaging with gating:
in the cirrhotic cardiomyopathy and may be of
c Regional myocardial perfusion
potential use in identifying patients at risk.
c Cardiac volumes
c Ejection fraction
c Wall motion and wall thickening CONCLUDING COMMENTS
Diastolic function Cardiovascular complications in cirrhosis may arise
c Echocardiography/MRI/MUGA: on the basis of combined humoral, nervous and
c E/A ratio haemodynamic changes. Cirrhotic cardiomyopathy
c Deceleration time suggests a systolic and diastolic dysfunction and
c A and E waves electrophysiological abnormalities. It is different
c Relaxation times
from alcoholic heart muscle disease and appears to
Most of the techniques mentioned have been validated in normal subjects be unmasked by procedures that stress the heart,
and patients with cardiac failure.
*Oxygen consumption (ml/min) = 126effect (W)/body weight (kg) such as pharmacological vasoconstriction, exercise,
+3.5). and by insertion of TIPS (Box 1).59 Potential
E/A ratio, ratio of early to late (atrial) phases of ventricular filling; MUGA, diagnostic tools primarily include echocardiography
multigated acquisition.
and ECG (table 5). The cardiovascular complications
in cirrhosis and cirrhotic cardiomyopathy may be
part of a multiorgan syndrome that affects the
phosphokinase A and channel phosphorylation. patients prognosis.1 2 No specific treatment can be
Several receptor and postreceptor defects have been recommended, and is largely empiric and supportive.
described in cirrhosis with reduced b-receptor Caution should be exercised with respect to stressful
density and sensitivity, and altered G protein and procedures, such as large volume paracentesis with-
calcium channel functions.4 80 All these defects may out adequate plasma volume expansion, TIPS inser-
explain both impaired chronotropic responses and tion, peritoneovenous shunting and surgery.4 Cardiac
electromechanical uncoupling. The coupling failure is an important cause of mortality after liver
between cardiac contractions and the arterial transplantation. On the other hand, liver transplan-
system is of major importance for the amount of tation has been shown to reverse systolic and
work performed by the left ventricular myocar- diastolic dysfunction and the prolonged QT inter-
dium, and thereby for the strain on the heart.14 46 In val.69 Thus, although the post-transplant pathophy-
addition, Ward et al have shown a decrease in K+ siological mechanisms are complex, liver
transplantation appears to be an effective treatment
currents in ventricular cardiomyocytes from cir-
of the cardiovascular complications of cirrhosis.
rhotic rats, which prolongs the QT interval.81 The
Improvement of left ventricular contractility
prolonged repolarisation time is reflected by a
with ACE inhibitors should be done with care, as
prolonged QT interval in a substantial fraction of
this may provoke severe arterial hypotension. b-
the patients with cirrhosis, which could lead to
Blockers have been shown to reduce acutely the
ventricular arrhythmias and sudden cardiac death,
prolonged QT interval and may, in addition to the
but the evidence from clinical studies is sparse.4 59 In
cardioprotective effects, be of benefit.79 82 However,
cirrhotic patients, the prolonged QT interval is
effects on morbidity and mortality remain to be
significantly related to the severity of the liver
shown in longitudinal studies.
disease, portal hypertension, portosystemic shunts,
Future studies should be directed towards a
elevated brain-type natriuretic peptide (BNP) and
delineation of the clinical importance of cardiovas-
pro-BNP, elevated plasma noradrenaline and reduced
cular complications and cirrhotic cardiomyopathy,
survival.79 82 83 The prolongation of the QT interval and randomised to examine benefits of the treat-
is partly reversible after liver transplantation and b- ments outlined above.
blocker treatment (fig 5).45 82 The prolonged QT
interval in cirrhosis should be considered an element Competing interests: None.
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These include:
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Notes