The diagnostic and prognostic utility of risk factors defined by the AHA/ACCF on the evaluation of cardiac disease in liver transplantation candidates

BACKGROUND: The diagnostic and prognostic utility of risk factors proposed by the 2012 American Heart Association and American College of Cardiology Foundation (AHA/ACCF) Scientific Statement on the cardiac assessment of asymptomatic liver transplantation candidates have not been validated. We investigated whether the sum of risk factors proposed by the AHA/ACCF can identify liver transplant candidates at increased cardiac risk. METHODS: In a retrospective cohort of consecutive liver transplantation recipients, we calculated, for each subject, the pre-transplantation sum of AHA/ACCF risk factors (age > 60 years, prior cardiovascular disease, hypertension, dyslipidemia, diabetes mellitus, smoking, and left ventricular hypertrophy). The primary outcome was the presence of severe coronary artery disease (CAD), defined as ≥70% stenosis or ≥ 50% left main stenosis on pre-transplantation angiography. The secondary outcomes were the composite of cardiac death or myocardial infarction (MI) and the composite of cardiac death, MI, or coronary revascularization. RESULTS: Among 220 liver transplant recipients, the sum of AHA/ACCF risk factors had good discriminatory capacity for severe CAD [area under the curve, 0.77; 95% confidence interval (CI), 0.62–0.92; P = 0.007]; having ≥3 risk factors provided 75% sensitivity and 77% specificity for severe CAD. During mean post-transplantation follow-up of 48 ± 31 months, having ≥3 risk factors was associated with increased risk of the secondary composite outcomes of cardiac death or MI [hazard ratio, 2.39; P = 0.044] and cardiac death, MI, or coronary revascularization [hazard ratio, 2.39; P = 0.044]. CONCLUSIONS: In patients undergoing cardiac assessment prior to liver transplantation, the sum of risk factors proposed by the AHA/ACCF provides significant diagnostic and prognostic utility. Having ≥3 AHA/ACCF risk factors is a reasonable threshold to prompt non-invasive stress testing in asymptomatic liver transplantation candidates.