Vascular, Valvular Calcification and Risk for CAD Before Liver Transplantation

Adding abdominal vascular, coronary artery, and valvular calcification status data to stress echocardiography data improves obstructive coronary artery disease (CAD) identification in patients with cirrhosis, according to results of a study published in the American Journal of Cardiology.

Patients with cirrhosis who receive orthotopic liver transplantation evaluation between 2000 and 2020 at Indiana University were eligible for this single-center, retrospective case-control study. A random sample of 88 patients with and 97 patients without obstructive CAD were included in this study. Identification of CAD was evaluated by adding independent variables using a nested logistic regression model. The model that best differentiated between patients with and without CAD was determined.

Patients with CAD were older (P =.003), more were men (P =.001), and more were on insulin (P =.007) than the patients without CAD. Among the CAD group, 64.8% had obstructive CAD.

An abnormal stress echocardiogram was defined as one with chest pain, ischemia, wall motion abnormalities, left ventricular augmentation failure with stress, mitral valve calcification, and/or aortic valve calcification. Abnormal echocardiograms occurred among 72.7% of patients with CAD and 46.4% without CAD (P =.003). An abnormal stress echocardiogram had an area under the curve (AUC) for detecting obstructive CAD of 0.58, sensitivity of 35.2%, specificity of 81.4%, positive predictive value (PPV) of 63.3, and negative predictive value (NPV) of 58.1.

Abdominal calcification was observed among 50% of patients with CAD and 36.1% of patients without CAD (P =.06) and coronary calcification among 28.4% and 22.7% (P =.008), respectively.

By adding aortic valve sclerosis or stenosis data to abnormal stress echocardiography data, the AUC for detecting obstructive CAD increased to 0.69. Adding mitral valve calcification data to aortic valve sclerosis or stenosis data and abnormal stress echocardiography data also had an AUC of 0.69. In each progressive model, adding abdominal calcification (AUC, 0.72), coronary calcium on computed tomography (AUC, 0.73), and age, gender, and diabetes requiring insulin status (AUC, 0.80) data increased the predictive power of the model.

The final model with all predictors was significantly more predictive than abnormal stress alone (P <.001) and had a sensitivity of 58.0%, specificity of 88.7%, PPV of 82.3, and NPV of 69.9 for detecting CAD.

The limitations of this study include the retrospective, single center design.

These data indicated that adding vascular calcification data to stress echo may improve CAD identification in patients with cirrhosis. “Our study should be considered explorative and hypothesis-generating,” the study authors wrote.  “Prospective studies evaluating the impact of vascular and valvular calcification and stress testing on the ability to identify obstructive CAD in patients with cirrhosis before liver transplant are needed.”