Published online Nov 27, 2018. doi: 10.4254/wjh.v10.i11.877
Peer-review started: July 17, 2018
First decision: August 20, 2018
Revised: September 13, 2018
Accepted: October 11, 2018
Article in press: October 11, 2018
Published online: November 27, 2018
The concept of cardiac involvement with coronary artery disease (CAD) in cirrhotic patients has been changing as patients listed for liver transplantation (LT) have become older and sicker. A previous study of dobutamine stress echocardiography (DSE) as a diagnostic and prognostic tool for LT candidates, published by Nguyen et al, which found that DSE had a high negative predictive value for adverse outcomes post-LT. This study tries to elucidate the problem of CAD screening in pre-LT patients.
There is a real need for protocols for cardiac evaluation of patients awaiting LT - particularly for cirrhotic patients. The American Association for the Study of Liver Diseases (AASLD) published a guideline in 2005 that recommends myocardial stress testing for every patient referred for LT. Nevertheless, the guideline published in 2012 by the American Heart Association (AHA and the American College of Cardiology (ACC), suggested that myocardial stress testing should be reserved for patients with three or more CAD risk factors. Better understanding the use of these tools might lead to better choices for pre-LT patients and better prognosis post-LT.
To evaluate the diagnostic value of DSE and myocardial perfusion scintigraphy (MPS) in predicting CAD in cirrhotic patients listed for LT, using invasive coronary angiography (ICA) as gold-standard. This could help clinicians choose the best test for predicting adverse cardiac events post-LT.
A systematic review and meta-analysis was performed. Searches were run on the electronic databases Scopus, Web of Science, EMBASE, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews and Opengray.eu. There was no language or date of publication restrictions. The reference lists of the studies retrieved were searched manually.
The search strategy retrieved 322 references for DSE and 90 for MPS. In the final analysis, 10 references for DSE and 10 for MPS were included. Pooled sensitivity was 28% and 61% for DSE and MPS and specificity was 82% and 74%, for diagnosis of CAD using ICA as gold-standard, respectively.
This study found that DSE and MPS do not have adequate sensitivity for determination of whether CAD is present, despite having significant specificity. There is a need for better tools in order to detect CAD in pre-LT patients. It is not feasible to determine whether AASLD or AHA/ACC is correct, hence both tests underperformed. It is proposed a hypothesis that new methods, tests or scores are need in order to clarify this question, which could impact pre-LT decisions in the future.
It is possible to conclude that current evidence regarding pre-LT cardiac stress testing is lacking, and future research are bound to focus into solving this important clinical question. A comprehensive study, cohort or randomized, is necessary in order to gather more information on the utility and feasibility of the use of current and future tests in order to determine the presence of pre-LT CAD.