Cardiac Cirrhosis:

#cardiaccirrhosis #chronicheartfailure #liverdysfunction #poorbloodflow #symptoms #diagnosis #treatment

Case Study : From HEART TO LIVER

Nearly 5-15% of patients with CHF develop cardiac cirrhosis

Mohan Prasad, a 60-year-old male from Dehradun , presented to my cardiology clinic in delhi with complaints of dyspnea and ascites. He had a history of coronary artery disease (CAD) and had undergone angioplasty 8 years ago. On examination, he had a distended abdomen with shifting dullness, and bilateral pedal edema. His liver was palpable 3 cm below the right costal margin . His heart sounds were normal, with no murmurs or gallops. However, his jugular venous pressure was elevated. His liver enzymes and serum bilirubin was raised. He was being treated on the lines of liver cirrhosis. He was non-alcoholic and hepatitis markers were negative.

He had profound dyspnea and weakness and was unable to walk short distances or climb stairs. He was brought along with all his records along with him. His Chest X-ray showed features of cardiomegaly with bilateral pulmonary congestion. His ECG showed

RBBB with multiple supraventricular ectopics. His 2D Echo was not done. He was on diuretics (tab Lasix 40 mg OD) and beta-blocker ( metoprolol XR 25 mg OD) apart from usual antiplatelets, statin , nitrocontin and ramipril for his CAD .

I asked for his 2D Echo and NT- proBNP ( natriuretic peptide) test straight away after his examination. His 2D - Echo showed Dilated Cardiomyopathy (DCMP ) with severe LV dysfunction (LVEF = 20% ). His NT- proBNP is above 8103 pmol/L. He was diagnosed as having CHF with Cardiac Cirrhosis, advised admission and is now undergoing treatment for heart failure .

What is Cardiac Cirrhosis?

Cardiac cirrhosis, also known as congestive hepatopathy, is a condition where liver damage occurs as a result of long-term heart failure. It is estimated that about 5-15% of patients with chronic heart failure develop cardiac cirrhosis. The condition is caused by reduced cardiac output, which leads to congestion in the liver and subsequent fibrosis. It is a type of secondary liver disease that occurs as a complication of chronic congestive heart failure.

In cardiac cirrhosis, the liver becomes congested with blood due to the heart's inability to pump blood effectively. This congestion leads to scarring and damage to the liver, which can cause a range of symptoms such as abdominal pain, ascites (fluid buildup in the abdomen), jaundice (yellowing of the skin and eyes), and fatigue.

Symptoms of Cardiac Cirrhosis :

• Dyspnea (shortness of breath)

• Ascites (abdominal swelling due to fluid accumulation)

• Bilateral pedal edema (swelling of feet)

• Elevated jugular venous pressure

• Palpable liver

• Fatigue

• Loss of appetite and weight loss

Diagnosis of Cardiac Cirrhosis

The diagnosis of cardiac cirrhosis is often challenging to physician as the symptoms are non-specific and can be similar to those of other liver diseases. The diagnosis is usually made by cardiologist and heart specialists based on a combination of clinical evaluation, imaging studies, and laboratory tests.

1. Clinical evaluation:

The cardiology doctor will perform a physical examination, which may include checking for signs of edema, ascites, and jaundice. The heart doctor may also check for other symptoms of chronic heart failure, such as shortness of breath and fatigue.

2. Diagnostic Tests:

• Blood tests: Elevated liver enzymes, elevated natriuretic peptide levels (indicative of heart failure)

• Electrocardiogram (ECG): May show signs of previous myocardial infarction or ischemia

• Echocardiography: Helps in assessing the heart function, ejection fraction, and valve function

• Liver ultrasound: To rule out other causes of liver dysfunction

• Chest X-ray: May show enlarged heart or signs of pulmonary edema

Diagnostic tests for Heart Failure

Types of Heart Failure:

There are two types of heart failure:

1. Systolic heart failure: The heart's pumping function is reduced, and it cannot pump enough blood to meet the body's needs. This can be caused by a variety of factors, including coronary artery disease, high blood pressure, and valve disease.

2. Diastolic heart failure: The heart's filling function is impaired, and it cannot relax enough to allow sufficient blood to flow into the heart.This can be caused by a variety of factors, including aging, high blood pressure, and diabetes.

Treatment of Cardiac Cirrhosis

The treatment of cardiac cirrhosis is aimed at managing the underlying chronic heart failure and improving liver function. The treatment options may include the following:

1. Medications: Medications may be prescribed by heart specialists to manage chronic heart failure and reduce the symptoms of cardiac cirrhosis.

The treatment of heart failure includes the following:

• Diuretics: To remove excess fluid from the body

• Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs): To improve heart function and reduce blood pressure

• Beta-blockers: To reduce the heart rate and improve heart function

• Aldosterone antagonists: To reduce fluid retention

• Digoxin: To improve heart function and control heart rhythm

2. Lifestyle changes: Lifestyle changes, such as a low-sodium diet and exercise, may be recommended to manage chronic heart failure and improve overall health.

Newer Heart failure medications:

HEART FAILURE MEDICINES

1. SGLT2 inhibitors:

SGLT2 inhibitors, which are a class of medications used primarily to treat type 2 diabetes, have been shown to have significant benefits in treating heart failure with reduced ejection fraction (HFrEF). These drugs work by blocking the action of the SGLT2 protein in the kidneys, which reduces the amount of glucose that is reabsorbed and increases the amount that is excreted in the urine.

In addition to their glucose-lowering effects, SGLT2 inhibitors have been found to have several beneficial effects on the cardiovascular system, including reducing the risk of heart failure hospitalizations, cardiovascular death, and all-cause mortality. These effects appear to be independent of their glucose-lowering effects and may be related to their ability to improve sodium and water balance in the body, reduce inflammation, and improve cardiac function.

Clinical trials have demonstrated the efficacy of SGLT2 inhibitors in reducing the risk of heart failure hospitalization and improving overall outcomes in patients with HFrEF.

For example, the DAPA-HF trial found that dapagliflozin, an SGLT2 inhibitor, reduced the risk of cardiovascular death and heart failure hospitalization by 26% in patients with HFrEF, regardless of whether they had diabetes or not.

The EMPEROR-Reduced trial similarly found that empagliflozin reduced the risk of cardiovascular death and heart failure hospitalization by 25% in patients with HFrEF.

SGLT2 inhibitors are generally well-tolerated and have a favorable side-effect profile. However, they can cause genital and urinary tract infections, as well as increase the risk of dehydration, hypotension, and ketoacidosis in some patients. As such, SGLT2 inhibitors should only be used under the guidance of a healthcare provider and in accordance with their approved indications and dosages.

2. Guanylate cyclase (sGC) stimulators:

Vericiguat is a medication used to treat heart failure with reduced ejection fraction. It is sold under the brand name Verquvo and is a member of a class of drugs known as soluble guanylate cyclase (sGC) stimulators.

Vericiguat works by increasing the activity of the sGC enzyme, which helps to increase the production of cyclic guanosine monophosphate (cGMP) in the blood vessels. This in turn leads to relaxation of the blood vessels, which can help to reduce the workload on the heart and improve blood flow to the body.

Vericiguat is typically prescribed in combination with other heart failure medications and is taken orally in tablet form. It is usually taken once a day with or without food, and the dosage may vary depending on individual patient needs.

It's important to note that vericiguat should only be prescribed by a healthcare provider after a thorough evaluation and that it may not be appropriate for everyone. Common side effects of vericiguat may include low blood pressure, dizziness, and headaches.

Newer Devices and Future Management:

Newer devices that are used in the management of heart failure include:

• Implantable cardioverter-defibrillator (ICD): It helps in preventing sudden cardiac death in patients with a history of arrhythmias.

• Cardiac resynchronization therapy (CRT):CRT is a device that is implanted in the heart to help improve cardiac function. It works by synchronizing the contractions of the heart's chambers, improving the heart's efficiency and reducing symptoms of heart failure.

• Ventricular assist devices (VADs): LVAD is a mechanical pump that is implanted in the heart to assist with blood flow. It is typically used in patients with severe heart failure who are awaiting a heart transplant.

• Stem cell therapy: Stem cell therapy is a promising new treatment for cardiac cirrhosis and chronic heart failure. Stem cells are injected into the heart, where they can regenerate damaged tissue and improve cardiac function.

• Gene therapy: Gene therapy is another promising new treatment for cardiac cirrhosis and chronic heart failure. It involves delivering genes to the heart that can improve cardiac function and reduce symptoms of heart failure.

Future management of heart failure includes the use of stem cell therapy and gene therapy to regenerate heart tissue and improve heart function. Additionally, artificial intelligence-based models may be used to predict heart failure before it occurs and improve patient outcomes.

Conclusion Cardiac cirrhosis is a rare but serious complication of chronic heart failure. It is caused by poor blood flow from the heart, leading to liver dysfunction and fibrosis. The symptoms of cardiac cirrhosis are non-specific and can be similar to those of other liver diseases. The diagnosis is often challenging and requires a combination of clinical evaluation, imaging studies, and laboratory tests. The treatment of cardiac cirrhosis is aimed at managing the underlying chronic heart failure and improving liver function. There are several newer devices and future management strategies being developed to improve the treatment of cardiac cirrhosis and chronic heart failure.