Liver and the Heart

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Information about Liver and the Heart

Published on January 15, 2008

Author: Marietta1


بسم الله الرحمن الرحيم :  بسم الله الرحمن الرحيم Liver and the Heart By Dr. Farook Redwan :  Liver and the Heart By Dr. Farook Redwan Prof. of cardiology & Internal medicine Mansoura Faculty of Medicine “As you can’t live without your heart you can’t live without your liver “ :  “As you can’t live without your heart you can’t live without your liver “ Heart in liver Disease Classification::  Heart in liver Disease Classification: Heart involvement in liver diseases : This will include heart affection in the following conditions : A) Viral hepatitis i- Acute . Ii- chronic (B) Schistosomal hepatic fibrosis : i- Schistosomal corpulmonale . ii- Endomyocardial fibrosis ( EMF) and restrictive cardiomyopathy iii- direct Schistosomal affection of the heart . (C) Liver cirrhosis : i- cirrhotic ardio-myopathy and myocardial dysfunction ii- pulmonary hypertension iii- Hepatopulmonary syndrome. IV-Endocarditis and pericarditis . V-diseases incidence of hypertension ,atherosclerosis and coronare artery disease. Disorders that involve both liver and heart :- :  Disorders that involve both liver and heart :- (D) Metabolic disorders (i)- Haemoochromatosis (ii)-Glycogen storage disease (type II,III,IV). (iii)- Diabetes mellitus (iv)- Mucopolysacharidosis . (E) Toxic disorders :- i- Alcohol. (F) Collagen diseases :- i- Rheumatiod arthritis ii- systemic lupus erythematosis . iii- Antiphospholipid antibody syndrome. Iv- systemic vasculitis . Disorders that involve both liver and heart :-:  Disorders that involve both liver and heart :- (G) Infective disorders:- (1) Syphiylis (2) Tuberculosis (3) Hydatid diseas (4) Trypanosomiasis (5) Cystocercosis (6) Fungal infections (H) Haematologic disorders: (1) Anaemias especially hemolytic (2) Leukemias and lymphomas. (3) Disseminated itravascular coagulation . (I) Others :- (1) Amyloidosis (2) Sacoidosis . (3) Hereditary haemorrhagic telangiectasia Slide7:  (J) Cardiovascular effects of some hepatic diagnostic and therapeutic interventions 1- Endoscopy and injection sclerotherapy or band ligaion 2- portosystemic shunt surgery and transjugular intrahepatic porto-systemic shunts and stents ( TIPS). 3- paracentesis abdominals . 4- hepatic transplantation (K) Miscellaneous : 1- congenital heart disease with : Congenital hepatic fibrosis (L)Direct pericardial involvement in Liver absess Liver maligancy Heart & The Liver :  Heart & The Liver Ischemic Hepatitis ( Hypoxic Hepatitis or Acute Hepatic Infraction):  Ischemic Hepatitis ( Hypoxic Hepatitis or Acute Hepatic Infraction) Constrictive Percarditis :  Constrictive Percarditis THE LIVER IN CONGESTIVE HEART FAILURE :  THE LIVER IN CONGESTIVE HEART FAILURE LIVER & HEART:  LIVER & HEART Viral Hepatitis :  Viral Hepatitis Slide14:  i-Acute Hepatitis Palpitation dyspnea , chestpain ,hypotension and sinus bradycaerdia ).Dehan et al ., (1946); Adler & Lyen ( 1947) Fulminant hepatitis and acute hepatic failure were associated with many cardiac complications , prolonged hypotension , pulmonary oedema & adult respiratory distress syndrome (ARDS) arrhythmias (AF,ventricuelar premature contraction) ECG abnormalities & even sudden cardiac death (Bell,1971,Gorden. 1989). Pericarditis with effusion was also reported after HBV infection (Adler et al ,1978). Impairment of systolic L.V functions was observed in patients with acute HBV infection by use of STIS ,The degree of impairment was more in patients with anaemia or high serum bilirubin .Prolonged QTc interval & QRS duration in the ECG was also observed in these patients (Maatti,1990). ii-Chronic Hepatitis :- Cardiac involvement in HBV associated vasculitis was reported by McMahon et al (1989) in 4 cases over 4 year follow up 2 with congestive heart failure & 2 with pericarditis . Slide15:  The association of chronic HCV hepatitis with polyarteries nodosa (PAN) has been suggested (cacoub et al ,1992, Deny et al., 1992 )(Carsonet al. , 1993). High frequencey of HCV infection was found in patients with dilated cardiomyopathy(16.9%) by Matsumori et al. ,1996). Also high seropositivity for anti-HCV was detected in patients with hypertrophic cardiomyopathy (6of35 cases (17.6%) & HCV-RNA was detected in the myocardium in 3 patients ( Matsumori et al. ,1995). Evidence for association between hepatitis C virus seropositivty and coronary artery disease :  Evidence for association between hepatitis C virus seropositivty and coronary artery disease One of the most interesting developments in recent years has been the idea that infective agents may induce a pro-inflammatory effect and have a crucial role in atherothrombosis (Shah 2001) . This theory proposed that a mutation or a viral agent may represent events able to transform a single smooth muscle cell into the progenitor of a proliferative clone ,introducing the concept that the plaque may be considered a monoclonal benign neoplasm. Slide17:  In particular ,very few data on the relation between hepatitis C virus (HCV) infection and atherosclerosis are available .However ,very recent results indicate that seropositivity for HCV shows a positive association with carotid artery plaque and carotid intima-media thickening ,independent from other risk factors for atherosclerosis (Ishizaka et al.2003). Slide18:  Vassalle et al (2004) suggesed that HCVserpoositivitiy might be considered in the clinical setting as one of the risk factors affecting the onset and development of CAD. Fyurther studies are needed at this point to verify the potential additive effect of HCV infection with respect to the presence of other pathogens .This study might be relevant for adding new predicative and prognostic factors to the CAD multifactorial entity . Hemochromatosis :  Hemochromatosis Slide20:  According to the Iron Disorders Institute ,the group at highest risk for HHC include: Males of Scotch-Irish,British ,Dutch ,German ,French,Spanish,Italian,( Norther western Eruopean ),or Mediterranean descent ,orwith a family history or premature death by heart attack ,liver disease ,diabetes ,arthritis ,importence ,neurological disorders or cancer . Women who no longer have a period due to menopause ,premature discontinuation of period or an hysterectomy and who have the same ancestry and family history listed above . Blood relative of this men and women . Anyone homozygous for HFE gene mutations. - Serum Iron - Serum transferrin - Serum ferritin - Biopsy:  - Serum Iron - Serum transferrin - Serum ferritin - Biopsy Slide22:  There are two known important mutations in HFE , named C282 Y and H63D.C282Y is the most important . Alcohlic CM and liver disease :  Alcohlic CM and liver disease Cirrhotic Cardiomyopathy :  Cirrhotic Cardiomyopathy Definition :-:  Definition :- A Cardiac dysfunction characterized by increased cardiac output and altered diastolic relaxation at rest associated with insufficient ventricular contractility under strain . Baseline features :  Baseline features High rest cardiac output . Abnormal diastolic relaxation as indicated by reduced E/A ratio and prolonged deceleration time at echocardiography . Mild enlargement of left ventricular chambers and mild increase of wall thickness. Prolonged Q-T interval . Features Occurring under strain:  Features Occurring under strain Blunted increase of cardiac output with tilting or vasoconstriction (increased after-load ) Blunted increase of left ventricular ejection fraction (LVEF) with exercise or reduced LVEF after standing . Blunted chronotropic response to isoproterenol . Reduced aerobic exercise capacity . Slide28:  The pathophysiological basis The presence of a hyperdynamic circulation which overloads heart with an impaired cardiac contractility ( Moller et al ( 1995 ) and Bernardi et al ( 1995 ) Structural cardiac changes Autonomic dysfunction Conductance abnormalities . Biochemical abnormalities Receptor/postreceptor defects “ Impaired beta –adrenergic signal transduction , abnormal plasma membrane fluidity , altered ion channel function may be important ( Ma et al ( 1996 ) and Zevecz et al ( 2000) . over production of nitric Oxide (NO), increased bile acid ,TNF- α , Endotoxius ,& endotheln. Investigation :  Investigation Biomarkers Elevated cardiac Tropnin I Increased BNP Increased palsma aldostesone Increased PRA ECG Q-T piolongation Echo Septal hypertrophy decreased E/A ratio Mild increase of LV chambers Mild increase of wall thickness Blunted increase of LVEF with exercise Slide30:  Biopsy Both macroscopic and microscopis changes have been described in cirrhotic hearts , thus septal hypertrophy has been described in a considerable number of cirrhotic patioents . Histological patchy fibrosis interstitiel oedema. Clinical Problems & Therapeutics:  Clinical Problems & Therapeutics Slide32:  CCM as a sub -clinical from of HF with no symptom at rest is not considered to need any special treatment . Patients with non compensated liver cirrhosis are usually subjects with limited exercise capacity and are usually under :- Slide33:  (1) Salt restriction ( to prevent water and sodium retention ) leading to decreased LV preload . (2) Peripheral vasodilatation (in the context of LCF ) decreases LV after -load and cardiac energy demands (3) Pharmacological treatment usually received with non –compensated liver cirrhosis includes drugs with a direct or indirect beneficial effect on the cardiovascular system Slide34:  Frusemide contribits to decreased renal reabsoption of sodium and water , decreasing the total plasma volume . Spironoloctone is considered to cause both . (a) Inhibition of renin-angiotension axis & (b) Improvement in LV remodeling . Wet Wise “W W “ or Dry Demented “D D”:  Wet Wise “W W “ or Dry Demented “D D” Slide36:  - Beta Blockers The use of BB ( propranolol ) in cirrhotic patients with portal hypertension and oesophegeal varices seems to have beneficial effect on B-adrenergic receptor density which is supposed to be down-regulated in cirrhosis Slide37:  Nitrates Combined with BB in portal hypertension have :- Coronary VD effect . Venodilatory effect with preload reduction Cardiovascular effects of some hepatic diagnostic and therapeutic interventions :  Cardiovascular effects of some hepatic diagnostic and therapeutic interventions Hepatic Transplantion :  Hepatic Transplantion Liver Transplantation :  Liver Transplantation constitutes a great physical stress for the cardiovascular system ,during both trans-operative and the postoperative period . Fifty six % ( 56 % ) of patients in certain series exhibited acute pulm oedema during the early postoperative period 7-21 % of postoperative deaths were attributed to heart failure . Slide41:  Postoperatively after-load augmentation due to : Progressive normdization of the hyperdynemic circulation Elevation of the peripheral resistance . Elevation of the arterial BP. Sampathkumar etal (1998) have described a reversible form of DCM during the early post transplanted period with clinical manifestations of prlm.och a Rosp.tale acute pulm-oedema respiratory failure.. Cardiovascular system alteration during the post – transplant period :  Cardiovascular system alteration during the post – transplant period Slide43:  (1)Navasa etal (1993) maintained that most of the humoral and hemodynaemic alterations in terminal stage liver disease are restored during the post transplant period . (2) Henderson etal ( 1992) suggested a residuel state of hyperdynamic circulation in the transplanted patients. (3)QT intervel prolongation is reversed during the posttransplant period as considered by Mochammad etal( 1996) and Gonzaleyz etal (1999). Liver transplants as a treatment for hyperlipidemia:  Liver transplants as a treatment for hyperlipidemia Slide45:  Interferon Cardiotoxicity of interferon therapy in chronic HCV hepatitis had been reported in 3.2% of patients ( Teragawa et al., 1996) and include arrhythmias ,ischemic heart disease and cardiomyopathy . Also , Sartori et al. 1996 reported decrease in LV ejection fraction with interferon therapy in chronic HCV hepatitis that return to pretreatment level after 3 months of the end of therapy . Kadayifei et al.,(1997) found no significant cardiac adverse effect by clinical examination or cardiovascular test in patients with chronic active hepatitis treated with interferon and concluded that it can be used safely in chronic active hepatitis patients . Sclerotherapy and band ligation:  Sclerotherapy and band ligation TIPS:  TIPS Abdominal paracentesis :  Abdominal paracentesis Cardiovascular Drugs & The liver :  Cardiovascular Drugs & The liver Conclusion :  Conclusion Slide51:  Myocardial dysfunction in patients with liver cirrhosis and serious hepatic failure is described by the term cirrhotic cardiomyopathy Because of its mild , subclinical course this entity remains under estimated , since these patients usually exhibit a variety of more serious complications related to hepatic failure and portal hypertension . Further research is needed to evaluate wheather this entity influences morbidity and mortality under certain circumstances that modify cardiovascular status , such as liver transplantation . In the meantime , evaluation of pre-transplant cardiovascular function is deemed to be necessary . Acknowledgement :  Acknowledgement Dr. Ahmed Abdullah Dr. Essam Mahfouz Dr. Abdel-Hamid Rashaad and Dr. Mohammad Khashaba

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