Coronary Artery Disease in
Decompensated Patients Undergoing
Liver Transplantation Evaluation
Samarth S. Patel,
Richard T. Stravitz,
Scott C. Matherly,
Velimir A. Luketic,
Richard K. Sterling,
Arun J. Sanyal,
and Mohammad Shadab Siddiqui
Divisions of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine;
Cardiology, Department of Internal
Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
Coronary artery disease (CAD) is an important contributor to morbidity and mortality in patients undergoing liver transplanta-
tion (LT). However, the current literature is limited by sampling bias and nondeﬁnitive assessment of CAD. The current study
examines the prevalence of CAD via per protocol coronary angiography and its relationship to etiology of liver disease in patients
undergoing liver transplantation evaluation (LTE). Data on 228 patients were prospectively collected who had coronary angiog-
raphy as part of LTE between 2011 and 2014. Coronary angiography was done in all patients age 50 years or with CAD risk
factors. CAD was deﬁned as any coronary artery stenosis, whereas stenosis 70% in distribution of 1 or 3 major coronary arter-
ies was considered as single- or triple-vessel disease. CAD was detected in 36.8% of patients, with the highest prevalence among
nonalcoholic steatohepatitis (NASH) patients with cirrhosis (52.8%). Prevalence of single-vessel disease was higher among
patients with NASH compared with hepatitis C virus (HCV) and alcoholic cirrhosis (15.1% versus 4.6% versus 6.6%; P 5 0.02).
Similarly, patients with NASH were more likely to have triple-vessel disease when compared with HCV and alcoholic cirrhosis
(9.4% versus 0.9% versus 0%; P 5 0.001). While adjusting for traditional risk factors for CAD, only NASH as etiology of liver
disease remained signiﬁcantly associated with CAD. Complications from diagnostic coronary angiography or percutaneous coro-
nary intervention were low (2.6%). In conclusion, patients undergoing LTE have a high prevalence of CAD, which varies widely
depending on etiology of liver cirrhosis. The procedural complications from coronary angiography are low.
Liver Transplantation 24 333–342 2018 AASLD.
Received August 14, 2017; accepted December 20, 2017.
Liver transplantation (LT) is the only curative therapy
for patients with decompensated cirrhosis.
LT is a
high-risk surgery performed in a fragile patient popu-
lation with a nearly 10% 1-year mortality. Thus, a
thorough evaluation prior to LT is essential to
minimize perioperative risk.
An integral component
of the liver transplantation evaluation (LTE) is coro-
nary artery disease (CAD) assessment as surgical mor-
bidity and mortality can be as high as 81% and 50%,
respectively, in patients with signiﬁcant CAD under-
Currently, there are no standardized
guidelines regarding CAD assessment in patients
undergoing LTE, reﬂecting the widespread variation
in practice across LT centers.
The deﬁnitive test of diagnosing CAD is coronary
angiography. However, it is often deferred in patients
with decompensated cirrhosis due to its invasive nature
and perceived increased risk of renal failure, bleeding,
and infectious complications.
tests such as coronary computed tomography (CT)
angiography or chemical stress test are often substituted
for coronary angiography. Although these tests have
adequate negative predictive value, the positive predic-
tive value is less accurate and therefore does not allow
Abbreviations: ALT, alanine transaminase; AST, aspartate transam-
inase; BMI, body mass index; BMS, bare metal stent; BUN, blood
urea nitrogen; CABG, coronary artery bypass grafting; CAD, coro-
nary artery disease; CI, conﬁdence interval; CLD, chronic liver dis-
ease; CT, computed tomography; GFR, glomerular ﬁltration rate;
HCV, hepatitis C virus; HD, hemodialysis; HDL-C, high-density lipo-
protein cholesterol; INR, international normalized ratio; IQR, inter-
quartile range; LDL-C, low-density lipoprotein cholesterol; LT, liver
transplantation; LTE, liver transplantation evaluation; MACE, major
adverse cardiovascular event; MELD, Model for End-Stage Liver Dis-
ease; MI, myocardial infarction; NASH, nonalcoholic steatohepatitis;
OM1, obtuse marginal 1; OR, odds ratio; PBC, primary biliary cholan-
gitis; PCI, percutaneous coronary intervention; RCA, right coronary
artery; SD, standard deviation; T2DM, type 2 diabetes mellitus.
PATEL ET AL.