Professional Documents
Culture Documents
Rahulpresentation Copy 140512102000 Phpapp02
Rahulpresentation Copy 140512102000 Phpapp02
RAHUL ARORA
JR-2
Chief Supervisor
PROF. RAVI MISRA
M.D.
Professor
Department of Medicine
Cardiovascular complications-
Two major cardiovascular complications-
1. Cirrhotic cardiomyopathy ;and
2. Hyperdynamic circulation-
have been shown to exist in cirrhotic patients (Lee et
al., 2007). .The exact prevalence of cirrhotic
cardiomyopathy remains unclear.
STUDY DESIGN
PATIENT PRESENTED IN OPD / EMERGENCY
PATIENT SELECTION
DIAGNOSIS OF CIRRHOSIS
SUBJECTS OF STUDY
CORRECTION OF COMPLICATION
ECG / ECHO
MATERIAL AND METHODS
PLAN OF WORK
A minimum of 40 consecutive patients of hepatic
cirrhosis admitted in medical wards ;and
Patient of age limit and sex matched controls were
included in study.
The controls were healthy persons with no history of
alcohol intake and no known cardio vascular or related
problems in whom clinical examination, biochemical
and other investigations were with in normal limits.
The diagnosis of cirrhosis was made on basis of
clinical evaluation, biochemical and ancillary
investigation like USG, upper GI endoscopy.
A detailed clinical history with specific reference to
CVS problems, alcohol intake and smoking was taken.
A complete general and systemic examination
particularly for stigmata of chronic liver disease and
cardio vascular status was carried out.
Inclusion Criteria :
All patients of cirrhosis of liver admitted in medical
wards of Gandhi Memorial and Associated Hospitals
of C.S.M. Medical University, Lucknow with
evidence of Hepatocellular dysfunction with portal
hypertension as evidenced by coarse echotexture
of liver with increased portal vein diameter >13 mm
on ultrasonography alongwith presence of
esophageal or gastric varices on endoscopy and/or
presence of cirrhosis of liver on biopsy (if possible)
shall be subjects of present study
Exclusion Criteria :
Established clinical cases of coronary artery disease with
overt florid evidence of stable angina, unstable angina or
myocardial infarction, congenital heart disease, rheumatic
heart disease, hypertension, thyroid gland disorders, diabetes
mellitus or baseline ECG abnormalities (e.g. left bundle
branch block, left ventricular hypertrophy and strain or pre -
excitation)
SYSTEMIC CIRCULATION
Plasma volume ↑ PULMONARY CIRCULATION
Pulmonary blood flow ↑
Total blood volume ↑
Pulmonary vascular resistance ↓ (↑)
Non-central blood volume ↑ RENAL CIRCULATION
Central and arterial blood volume →↓ (↑) Renal blood flow ↓
Renal vascular resistance ↑
Cardiac output (→) ↑
CEREBRAL CIRCULATION
Arterial blood pressure →↓ Cerebral blood flow ↓ →
Heart rate ↑ CUTANEOUS AND SKELETAL
Systemic vascular resistance ↓
MUSCLE CIRCULATION
Cutaneous blood flow →↑
HEART Skeletal muscular blood flow →
Left atrial volume ↑
Left ventricular volume → (↓)
Right atrial volume→↑↓
Right ventricular volume →↑↓
Right atrial pressure →↑
Right ventricular end-diastolic pressure →
Pulmonary artery pressure →↑
Pulmonary capillary wedge pressure →
Left ventricular end-diastolic pressure →
Tables 2 and 3 summarise various studies done to show blunted
cardiovascular response to various physiologic and pharmacologic
stimuli in patients with cirrhosis.
IMPLICATION
Patients with QTc interval prolongation exhibited high
mortality, more likely due to the advanced hepatic
disease than to a higher incidence of sudden cardiac
death in this special group of patients.
MECHANISM OF ACTION
Electro physiological changes including prolonged
repolarization and impaired cardiac excitation –
contraction coupling have been demonstrated in
cirrhotic patients. Repolarization prolongation is
manifested by a prolonged QT interval on the
electrocardiogram. Rate corrected prolongation of the
QT (more than 440 msec) is found in 30 – 60 % of
patients with cirrhosis (Bal and Thuluvath, 2003).
MALE
FEMALE
32
SEVERITY OF CIRRHOSIS
10%
15%
CHILD A
CHILD B
CHILD C
75%
ECG CHANGES IN CIRRHOTIC PATIENT
19%
PROLONGED QT
INTERVAL
T WAVE
55% INVERSION
26% WNL
PRO-BNP LEVEL IN CIRRHOTIC
PATIENT
CHILD A 468.2 40-1237
CHILD B 878 44.53-3010
CHILD C 1820.7 247-5010
PRO-BNP
2000
1500
1000
PRO-BNP
500
0
CHILD A CHILD B CHILD C
TROP –I LEVEL IN CIRRHOTIC
PATIENT
CHILD A 0.03-0.107 0.087
CHILD B 0.09-0.237 0.1464
CHILD C 0.03-0.549 0.2275
TROP I
0.25
0.2
0.15
TROP I
0.1
0.05
0
CHILD A CHILD B CHILD C
ECHOCARDIOGRAPHY
hyperdynamic circulation
raised lvef % as compared to control
fractional shortening decreased
only few patients have decrease ef
which improved in some patients on
follow up
grade 1 diastolic dysfunction, with
prolonged deceleration time with e/a
ratio <1
left atrial dimension increased
ECHO
8%
30% NORMAL
DIASTOLIC
DYSFUNCTION
SYSTOLIC
DYSFUNCTION
62%
E/A
1.2
0.8
0.6
E/A
0.4
0.2
0
CHILD A CHILD B CHILD C
References
1. Liu H, Lee SS: Cardiopulmonary dysfunction in
cirrhosis. J Hepatol Gastroenterol 1999; 14: 600-
608.
2. Lehmann MH: QT prolongation in end-stage liver
disease: a result of altered sex hormone
metabolism? Hepatology 1997; 26: 244
3. Mochamad R, Forsey PR, Davies MK, Neuberger
JM: Effect of liver transplantation on QT interval
prolongation and autonomic dysfunction in end-
stage liver disease. Hepatology 1996; 23: 1128-
1134
4. Pateron D, Beyne P, Laperche T et al. Elevated
circulating cardiac troponin I in patients with
cirrhosis. Hepatology 1999; 29: 640–3
5. Nunes JP. Cardiac troponin I in systemic diseases. A
possible role for myocardial strain. Rev Port Cardiol.
2001; 20: 785-8
6.Karasu Z, Mindikodlu AL, Van Theil D H. Cardiovascular
problems in cirrhotic patients. The Turkish Journal of
Gastroenterology 2004; 15: 126-132
7.Wong, Gut 2001; 49:268-275 doi:10.11 36/gut.49.2.268.
8. Moller S and Henriksen JH. Cirrhotic cardiomyopathy: A
pathophysiological review of circulatory dysfunction in
liver disease. Heart 2002;87:9-15.
9. Bal JS and Thuluvath PJ. Prolongation of QTc interval:
relationship with etiology and severity of liver disease,
mortality and liver transplantation, Liver Int. 2003;
23:243-8.
10. Waleed K. Al-hamoudi, Cardiovasular change in
cirrhosis : Pathogenesis and clinical
implications, The Saudi Journal of Gastroenterology,
Volume 16, Number 3, July 2010
11.Moller S and Henriksen JH. Cardiovascular
dysfunction in cirrhosis. Pathophysiologic evidence of a
cirrhotic cardiomyopathy. Scand J Gastroenterol 2001;
36: 786–794.
12. Ma Z. and Lee SS. Cirrhotic cardiomyopathy:
getting to the heart of the matter. HEPATOLOGY 1996;
24: 451–459.
13. Ward CA, Liu H and Lee SS. Altered cellular
calcium regulatory systems in a rat model of cirrhotic
cardiomyopathy. Gastroenterology 2001; 121: 1209–
1218.
14.Ceolotto G, Papparella I, Sticca A, et al. An
abnormal gene expression of the β-adrenergic system
contributes to the
pathogenesis of cardiomyopathy in cirrhotic rats
MOLECULAR MECHANISM
Pathogenic Mechanisms of Cirrhotic Cardiomyopathy
1.1 β-Adrenergic Receptor Signalling
In view of the relationship between the β-adrenergic receptor and cardiac
contractility, this system has been subjected to detailed study in cirrhotic
cardiomyopathy.
The G-protein subunits, Gs and Gi2α, are significantly decreased, in both content
and function, without any change to the Gβ subunit. cAMP generation was also
shown to be attenuated in BDL. This decrease of cAMP is due to impairment of
adenylyl cyclase activity, which is partly secondary to decreased G-protein
stimulation of the catalytic subunit of the enzyme, and also due in part to an
inhibitory effect of jaundice (Ma et al., 1999).
.1.2 Membrane Fluidity
Membrane fluidity represents the freedom with which lipid and protein molecules
are able to move in the plasma membrane lipid bilayer. Several studies have
demonstrated that in cirrhosis, the plasma membrane fluidity in cells from the heart
(Ma et al., 1994), erythrocytes (Kakimoto et al., 1995), kidneys (Imai et al., 1992)
and liver (Reichen et al., 1992) is abnormal, and in some cases have reduced
fluidity due to an increase in membrane cholesterol content. & play an integral role
in diminished β-adrenergic receptor functioning through interference with G-protein
coupling (Ma et al., 1997) and cAMP production (Ma et al., 1994). This suggests
that alterations in plasma membrane fluidity play an important role in the β-
adrenergic receptor dysfunction and thus in the pathogenesis of cardiac
contractility in cirrhosis.
1.3 Endocannabinoids
By definition, endogenous cannabinoids or endocannabinoids are endogenous
ligands capable of binding to and functionally activating cannabinoid receptors- CB1
and CB2.
Since their discovery, anandamide and 2-arachidonoylglycerol have been implicated
in a variety of physiological and pathological processes.
arterial hypotension observed in cirrhotic rat models (Batkai et al., 2001; Ros et al.,
2002). M as a selective splanchnic vasodilator in cirrhosis acting predominately
through two receptors- one of which is CB1 (Domenicali et al., 2005).
Gaskari et al demonstrated a negative inotropic effect of anandamide in left
ventricular papillary muscles of cirrhotic rats).
1.4 Calcium Kinetics
Stimulation of the β-adrenergic pathway or excitation-contraction coupling leads to
the activation of numerous calcium related systems that are crucial for cardiac
contraction. Studies performed on the cellular calcium dynamic in our BDL
cardiomyocytes showed a significant decrease in receptor density and
electrophysiological function of voltage-gated L-type Ca2+ channel (ICa,L)
compared to control myoctes (Ward et al., 2001).
ICa,L protein expression is quantitatively decreased in BDL cardiomyocytes.
1.5 Nitric Oxide
Balligand et al found that the inhibition of NOS synthesis by L-NMMA significantly
increased the contractile response of rat ventricular myocytes to the β-agonist
isoproterenol without affecting baseline contractility (Balligand et al., 1993). In the BDL
cirrhotic model, baseline isoproterenol-stimulated papillary muscle contractile force
was shown to be lower than in the control groups. However, when the papillary
muscles were preincubated with the NOS inhibitor L-NAME, contractile force increased
significantly in the cirrhotic rats, whereas control muscles were unaffected (Liu et al.,
2000). This group also showed that cirrhotic cardiomyocytes have an increased iNOS
mRNA and protein expression, whereas eNOS shows no significant difference in
expression between the BDL and the sham control hearts.
Table 1: proposed diagnostic criteria and supporting criteria for cirrhotic cardiomyopathy
Definition of the working group recommended in cirrhotic cardiomyopathy
Cardiac dysfunction in cirrhotic patients, in the absence of other known cardiac disease, blunt the
contractile response to stress, and / or
an entity characterized by impaired diastolic relaxation with electrophysiological abnormalities.
Diagnostic criteria
Systolic dysfunction
- Exercise, inadequate cardiac output to increase in volume changes, or pharmacologic stimuli
- Resting ejection fraction <55% of
Diastolic dysfunction
- E / A ratio <1.0 (age-adjusted)
- Prolonged deceleration time (> 200 ms)
- Prolonged isovolumetric relaxation time (> 80 ms)
Supportive criteria
- Electrophysiological abnormalities
- An abnormal response to chronotropic
- Electromechanical uncoupling / dyssynchrony
- Prolonged Q-Tc interval
- Enlarged left atrium
- Increased myocardial mass
- Increased BNP and pro-BNP
- Elevated troponin I
BNP, brain natriuretic peptide, the E / A ratio: ratio of early to late (atrial) phases of ventricular filling.
Hemodynamic Study. After an overnight fast, patients were placed
in the supine position for at least 2 hours and were sedated with
meperidine hydrochloride, 50 mg intramuscularly. Arterial pressure
was monitored with an external sphygmomanometer (Dinamap,
Critikon, Tampa, FL) and heart rate was monitored by continuous
ECG tracing. Mean right atrial, mean pulmonary artery, and
pulmonary wedged pressures as well as wedged and free hepaticvenous
pressures were measured as previously described.8 Cardiac
output was measured by the thermodilution method with a Swan-
Ganz catheter placed in the pulmonary artery. Stroke volume index
was calculated according to the following formula: stroke volume
index 5 cardiac output/heart rate per body mass.
Echocardiography. All echocardiographic examinations were performed
by using commercial devices (Vingmed 700 CFM, Sonos
1500, Hewlett-Packard, Horten, Norway) and interpreted by the
same expert echocardiographer who was unaware of the hemodynamic
and biochemical results using commercially available devices.
A qualitative approach eliminated segmental abnormalities in left
ventricular contraction. Quantitative analysis was performed by
measuring the dimensions of the left ventricular internal cavity and
septal and posterior wall thickness by the long axis parasternal
approach. Left ventricular mass was calculated by using a previously
validated method9 and corrected by body surface area.