What is Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)?
Cirrhotic cardiomyopathy (CCM) is a serious health issue that can happen to those with liver disease known as cirrhosis. It causes issues with how the heart contracts and relaxes, and can even lead to the heart becoming larger. This problem can occur even if there weren’t any previously known heart disorders. The term “CCM” was first used in 1989.
CCM is identified by the heart not reacting well under stress, an overactive circulatory system, issues with heart function, and other changes in heart rhythm, most notably a longer QT interval. It impacts up to half of those suffering from cirrhosis, irrespective of what caused the cirrhosis initially. People who have an alcohol use disorder or hemochromatosis, a condition of iron overload, are more likely to develop heart disease. Since CCM usually shows up under stress, it often goes unnoticed and does not have a standardized treatment plan. However, it’s been observed that significant improvements or even complete recovery from CCM can occur after a liver transplant.
What Causes Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)?
Cirrhotic cardiomyopathy (CCM) is caused by an advanced liver disease called cirrhosis, no matter what originally caused the cirrhosis. However, if someone has a history of alcohol misuse or a condition called hemochromatosis, these can add extra risks for heart problems. There’s also a direct link between how severe the liver disease is, as shown by a measurement called the Model For End-Stage Liver Disease score, and how severe the heart condition is. As of now, no identified genetic factors make someone more likely to develop CCM.
Risk Factors and Frequency for Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
Patients with Cirrhotic Cardiomyopathy (CCM) usually don’t show symptoms and their heart function appears normal unless under stress. This makes it difficult to determine exactly how many people have this condition. However, it’s estimated that up to half of people with a liver disease called cirrhosis might have some level of heart compromise. Those with moderate to advanced cirrhosis – a level known as Child-Pugh Class B or C – will usually exhibit at least one characteristic of CCM, such as a particular type of heart rhythm issue (QT prolongation) or an issue with how the heart fills with blood (diastolic dysfunction).
When patients with cirrhosis undergo liver transplantation, about half of them are noted to experience heart dysfunction around the time of the operation. Furthermore, 7% to 21% of these patients die from heart failure in the months after the transplant. Limited studies also suggest that CCM is more common in men, people over 50, and those whose cirrhosis is due to alcohol abuse.
Signs and Symptoms of Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
Cirrhotic cardiomyopathy (CCM) often doesn’t cause noticeable symptoms in many patients. This is due to the widening of blood vessels which lessens the load on the heart, despite some issues in how the heart functions. Even so, during times of stress, certain changes in the body’s blood flow and a compromised response from the heart might lead to symptoms of acute heart failure. Patients with moderate to severe liver disease (known as Child-Pugh Class B or C cirrhosis) who show signs of exercise intolerance, increasing tiredness, and swelling in the legs and ankles, especially if they have no known heart disease, should be suspected to have CCM. These symptoms, being fairly generic, often coincide with those of progressing liver disease, leading to frequent cases where CCM is overlooked or misdiagnosed.
During a physical check-up, you can usually expect no obvious signs of heart and lung disease. However, under conditions of stress, whether caused by the body’s natural response, medication, or disease, symptoms of congestive heart failure might start showing up. Common signs like swelling in the legs and ankles, distended neck veins, and certain abnormal heart sounds are likely to be observed. Alongside this, it’s crucial for doctors to watch for typical signs of liver disease such as yellowing of the skin or eyes, build-up of fluid in the abdomen, and an enlarged liver.
- Exercise intolerance
- Increasing tiredness
- Swelling in the legs and ankles
- Distended neck veins
- Abnormal heart sounds
- Yellowing of the skin or eyes
- Build-up of fluid in the abdomen
- Enlarged liver
Testing for Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
In 2005, the World Congress of Gastroenterology in Montreal recognized standard parameters for diagnosing Cirrhotic Cardiomyopathy (CCM), a condition that affects the heart in people with liver disease. These parameters involve specific signs of dysfunction in the way your heart contracts and relaxes, along with other supportive measures like abnormalities in the heart’s electrical activity, bigger than normal left heart chamber, thicker heart walls, and increased levels of certain proteins in your blood.
When checking for heart involvement in this condition, doctors may order tests for specific proteins in blood such as atrial natriuretic peptide, brain natriuretic peptide or its prohormone N-terminal pro-brain natriuretic peptide, and troponin I. They may also check for galectin-3, which is a sign of heart fibrosis. An electrocardiogram (ECG) can show if there’s a longer than normal time interval between each heartbeat, which is often the first sign of CCM. This time interval can vary between daytime and nighttime due to natural daily changes in our nervous and circulatory systems.
A chest X-ray may appear normal, but it can sometimes show an enlarged heart and signs of fluid in the lungs. An echocardiogram (a kind of ultrasound of the heart) is vital for diagnosis as it can show problems with the heart’s contraction and relaxation. Additional tests like Speckle tracking can be used to provide more details about the heart’s functioning. A stress test, where the heart’s response to exercise or medication is monitored, can be helpful in confirming the diagnosis of CCM, as the condition usually shows up under stress situations.
Patients with severe liver disease (cirrhosis) can have a hyperactive heart contraction when at rest, which may lead to a limited capacity for the heart to contract more when needed. According to the World Congress of Gastroenterology, having less than a 5% increase in the normal value of how efficiently the heart pumps blood during stress testing implies a decreased reserve for heart contraction, which may signal an underlying fault in the heart’s contraction mechanism. Still, because there are no uniformly agreed criteria, the 2019 diagnostic guidelines for CCM did not include stress echocardiography for finding impaired contractile reserve. However, stress echocardiography is still known for identifying problems in heart relaxation and may be useful in diagnosing CCM.
Treatment Options for Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
Currently, there is no standardized treatment or specific medications for cardiomyopathy related to cirrhosis (CCM). Patients are usually given standard heart failure treatments, and their need for liver transplantation is evaluated.
The common treatment includes medication such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, different types of water pills, aldosterone receptor antagonists, and beta-blockers. ACE inhibitors can help in reducing heart failure difficulties and risks, but they should not be used by patients with advanced liver disease as they can worsen their condition. Diuretics (water pills) are critical to manage fluid build-up. Aldosterone receptor antagonists improve heart workings by managing the continuous activation of the renin-angiotensin-aldosterone system, a hormone system that regulates blood pressure and fluid balance. Patients with cirrhosis likely already take beta-blockers to help reduce blood pressure in the liver and prevent internal bleeding. A specific type of beta-blocker, carvedilol, has been suggested to be more effective in reducing liver blood pressure and has shown to help manage irregular heartbeats.
A medical procedure called transjugular intrahepatic portosystemic shunt placement is used to reduce blood pressure in patients with liver cirrhosis, but it does not improve cardiomyopathy. Since CCM develops due to cirrhosis, liver transplantation is the key treatment. Studies have shown significant improvement in systolic and diastolic dysfunction and normalizing heartbeat irregularities in 50% of patients post transplantation. These heart benefits are usually seen within 3 to 12 months following surgery. However, it’s not yet known to what extent the heart can return to normal after liver transplantation.
What else can Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis) be?
When treating patients with CCM (congestive cardiomyopathy), doctors also consider other similar conditions that could be causing the symptoms. The list includes:
- Alcoholic cardiomyopathy (heart disease caused by excessive alcohol intake)
- Other types of dilated cardiomyopathy (a disease where heart chambers enlarge and can’t pump properly)
- Hypertrophic cardiomyopathy (a disease where heart muscle becomes abnormally thick, making it harder for the heart to pump blood)
- Restrictive cardiomyopathy (a rare heart disorder where the heart muscle becomes rigid and less elastic, preventing it from properly expanding and filling with blood)
It’s crucial for the doctors to consider these possible conditions and carry out the appropriate tests to come up with a correct diagnosis.
What to expect with Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
Cirrhosis, or scarring of the liver, generally leads to a poor health outcome, which is made even worse when Cirrhotic Cardiomyopathy (CCM) develops as well. Additional concerns like left ventricular diastolic dysfunction (a heart condition) or a high Child-Pugh score (an indicator of liver disease severity) can worsen the prognosis. In a study, patients with cirrhosis but without the heart condition had a 95% chance of surviving a year. This survival rate dropped to 79% and 39% for those who have a mild or severe case of the heart condition.
While liver transplantation can be a definitive treatment for CCM, up to a fourth of patients with cirrhosis may experience heart-related complications after surgery, leading to a 7% to 21% mortality rate from heart-related causes.
It’s not entirely clear how CCM affects overall survival rates, but because of its significance, it’s recommended that patients with cirrhosis get screened for CCM. Distinguishing the specific impact of CCM and cirrhosis is tough because the two conditions progress together. CCM does significantly affect outcomes after liver transplantations. An investigation into 141 patients who had liver transplants found that those without CCM had an 85.2% chance of surviving five years without heart disease, versus a 60.7% chance for those with CCM. This difference was particularly noticeable in the first 90 days after the transplant, emphasizing the need for careful monitoring and management of patients with CCM after a liver transplant.
Possible Complications When Diagnosed with Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
The complications related to CCM, or cardiomyopathy, may include:
- Congestive heart failure
- Arrhythmias – irregular heart rhythms
- Pulmonary hypertension – high blood pressure that affects the arteries in the lungs and the right side of the heart
- Hepatorenal syndrome – a condition that causes kidney failure in people with severe liver problems
- Sudden cardiac death – an unexpected death due to heart problems
Preventing Cirrhotic Cardiomyopathy (Impaired Heart Function Due to Cirrhosis)
It’s crucial for patients to understand the importance of taking their medications as prescribed, following dietary limits (like reducing salt intake), and having regular check-ups. They also need to know about the requirements for a liver transplant and be able to identify the signs of sudden heart failure. These are all key aspects of managing their health.
