CIRRHOTIC

CARDIOMYOPATHY

WHAT IS IT

Increased basal cardiac output with cardiac dysfunction

during stress in the setting of liver cirrhosis.

CRITERIA

1. baseline increased cardiac output w/ decreased function

during stress
2. Electrophysiologicalabnormalities
3. Diastolic or systolic function
4. Absence of HF during rest
5. No evidence of heart pathology

PHYSIOLOGY

MORE PHYSIOLOGY

Arterial vasodilation effective hypovolemia SNS and

RAAS
Hyper dynamic circulation

Cirrhosis

NOS
hepatic vascular resistance
splanchnic NO

Hypo reactive circulation

PHYSIOLOGY

ELECTROPHYSIOLOGY

QT prolongation ( might be the best indicator to

determine CC)
Electrical and Mechanical Dyssynchrony
-K+ channels

Ionotropic and Chronotropic incompetence

-L-type Ca2+
Diastolic Dysfunction
Role of CO and NO
Systolic dysfunction

A working definition of cirrhotic cardiomyopathy

A cardiac dysfunction in patients with cirrhosis characterised by impaired

contractile responsiveness to stress and/or altered diastolic relaxation with
electrophysiological abnormalities in the absence of other known cardiac disease
Diagnostic criteria
Systolic dysfunction
Blunted increase in cardiac output with exercise, volume challenge or
pharmacological stimuli
Resting EF <55%
Diastolic dysfunction
E/A ratio <1.0 (age-corrected)
Prolonged deceleration time (>200msec)
Prolonged isovolumetric relaxation time (>80msec)
Supportive criteria
Electrophysiological abnormalities
Abnormal chronotropic response
Electromechanical uncoupling/dyssynchrony
Prolonged QTc interval
Enlarged left atrium
Increased myocardial mass
Increased BNP and pro-BNP
Increased troponin I

DIAGNOSTIC STUDIES

EKG
E/A ratio
EKG
Stress test

MARKERS

E/A RATIO

QT PROLONGATION

RESPONSE TO LTX

CARDIAC PERFORMANCE
AFTER TIPS

Worsen hyperdynamic flow increased CO & decreased

SVR
Over time this can cause HOCF
If TIPS is tolerated then patient tend to normalize after 6
mo-1 year

CONCLUSIONS

reduced -adrenergic receptor activation leading poor

contractility
Usually unmasked during stress
No specific therapy indicated to prevent this
phenomenon
Vasodilators should be avoided
Cardiac glycosides have shown no significant
improvement
B-blockers have been shown to reduce hyperdynamic
load and decrease the QT prolongation
Liver transplant seems to improve most of the cardiac
dysfunction

CITATIONS

1.Cirrhotic cardiomyopathy
Mller, Sren et al. Journal of
Hepatology , Volume 53 , Issue 1 ,
179 - 190
2. Zardi EM, Abbate A, Zardi D, et al.
Cirrhotic Cardiomyopathy.J Am Coll
Cardiol.2010;56(7):539-549.
doi:10.1016/j.jacc.2009.12.075.