Is diastolic dysfunction prevalent in cirrhosis of the liver?

Diastolic Dysfunction in Cirrhosis: Prevalence and Clinical Significance

Yes, diastolic dysfunction is highly prevalent in cirrhosis, occurring in approximately 40-64% of patients, with the highest rates seen in those with decompensated disease and ascites. 1, 2

Prevalence Data

The prevalence of left ventricular diastolic dysfunction (LVDD) in cirrhotic patients varies considerably across studies but is consistently substantial:

• Overall prevalence ranges from 38-67% in patients with cirrhosis, with systematic review data showing 51.2% of cirrhotic patients have LVDD 1, 2
• Grade I diastolic dysfunction is most common (59.2% of those with dysfunction), while Grade III is rare (5.1%) 2
• Prevalence increases with disease severity: 44.6% in Child-Pugh A, 62% in Child-Pugh B, and 63.3% in Child-Pugh C patients 2
• Diastolic dysfunction approaches 40% in patients awaiting TIPS procedures specifically 1
• Significantly higher rates in decompensated cirrhosis: 62.9% in patients with ascites or variceal bleeding 3

Relationship to Disease Severity

The correlation between diastolic dysfunction and cirrhosis severity shows important patterns:

• Diastolic dysfunction is more prevalent in patients with ascites compared to those without (77% vs 56%) 4
• The proportion of patients with higher-grade diastolic dysfunction increases with more severe cirrhosis presentation 2
• However, MELD scores do not consistently correlate with presence or absence of diastolic dysfunction 2
• Diastolic dysfunction occurs as an early manifestation of cirrhotic cardiomyopathy, often in the setting of normal systolic function 1, 5

Diagnostic Criteria

According to EASL guidelines, diastolic dysfunction should be diagnosed using ASE (American Society of Echocardiography) criteria 1, 5:

• Average E/e' ratio >14
• Tricuspid velocity >2.8 m/s
• Left atrial volume index (LAVI) >34 ml/m²

Prognostic Implications

The presence of diastolic dysfunction carries significant prognostic weight, though data shows some variability:

Evidence supporting poor prognosis:

• One-year survival rates differ dramatically by dysfunction grade: 95% without diastolic dysfunction, 79% with Grade I, and only 39% with Grade II dysfunction 1
• E/e' ratio is an independent predictor of survival in multivariate analysis 1
• Diastolic dysfunction independently predicts mortality in decompensated cirrhosis, with significantly lower survival rates (31.1 vs 42.6 months) 3
• 38% of patients with diastolic dysfunction develop hepatorenal syndrome type I 1

Conflicting evidence:

• Some prospective studies show no relationship between cardiac dysfunction and survival, even in decompensated patients with Grade II dysfunction 1
• One large retrospective study found no difference in one-year mortality between patients with and without diastolic dysfunction undergoing abdominal surgery (22.2% vs 20.8%) 6

Clinical Context and Mechanisms

Diastolic dysfunction in cirrhosis occurs as part of cirrhotic cardiomyopathy, characterized by 5:

• Blunted contractile response to stress
• Altered diastolic relaxation
• Electrophysiological abnormalities (QTc prolongation in 79% of patients) 7
• Increased left ventricular mass and left atrial enlargement 1

Systemic inflammation plays a key pathogenic role, with lipopolysaccharide binding protein levels correlating with diastolic dysfunction severity and E/e' ratios 1

Impact on Interventions

TIPS Procedures

• Cardiac assessment is mandatory before elective TIPS placement, with 2D echocardiography to assess LVEF as standard practice 1, 5
• Three prospective studies (n=33-101) reported diastolic dysfunction relates to post-TIPS mortality within one year, though only 3/144 deaths were attributed to cardiac failure 1
• Five more recent studies found no relationship between diastolic dysfunction and post-TIPS survival or cardiac failure 1
• Post-TIPS symptomatic heart disease is rare (0.9% in one large study of 883 patients) 1

Liver Transplantation

• 43% of transplant recipients have diastolic dysfunction pre-transplant (compared to only 2% with systolic dysfunction) 1
• Diastolic dysfunction may be reversible: following transplantation, there is significant improvement in systolic strain and reduced left ventricular mass 1, 8
• Patients with BNP levels >391 on day one post-transplant have higher mortality and longer dialysis requirements 1, 5

Important Clinical Caveats

• Diastolic dysfunction is largely subclinical at rest, with overt heart failure seen mainly during stress, TIPS, or transplantation 7
• Cardiac loading conditions are confounding factors in diagnosis, as the hyperdynamic circulation of cirrhosis affects echocardiographic parameters 4
• Standardized criteria and protocols for assessment of diastolic function in cirrhosis are still needed 1, 5
• QTc prolongation (>0.44 seconds) occurs in 79% of cirrhotic patients and correlates with Child-Pugh and MELD scores, potentially serving as an early indicator 7

Practical Recommendations

For routine assessment:

• Detailed functional cardiac characterization should be part of assessment for TIPS insertion or liver transplantation 1
• Use ASE guidelines for diagnosis: E/e'>14, tricuspid velocity >2.8 m/s, LAVI >34 ml/m² 1, 5
• Consider NT-proBNP levels <125 pg/mL to identify patients not at risk of cardiac decompensation before TIPS 1

For high-risk patients:

• Decision-making should involve a multidisciplinary team including gastroenterology/hepatology, interventional radiology, anesthesia/intensive care, and transplant physicians when appropriate 1
• Agents that prolong QT interval should be used cautiously in all cirrhotic patients 1, 5