Clinical Investigations: Acute Ischemic Heart Disease
Heart diseases affecting the liver and liver diseases affecting the heart

https://doi.org/10.1067/mhj.2000.107177Get rights and content

Abstract

Background The association of cardiac and liver disorders has not been extensively outlined in the literature. Methods A survey of the MEDLINE database was performed to assess the current status of research regarding the association between cardiac and liver disorders. Results Combined cardiac and hepatic disorders occur in 3 different settings: heart diseases affecting the liver, liver diseases affecting the heart, and cardiac and hepatic disorders with joint etiology. The spectrum of heart diseases affecting the liver includes mild alterations of liver function tests in heart failure, cardiogenic ischemic hepatitis, congestive liver fibrosis, and cardiac cirrhosis. The liver diseases affecting the heart include complications of cirrhosis such as hepatopulmonary syndrome, portopulmonary hypertension, pericardial effusion, and cirrhotic cardiomyopathy as well as noncirrhotic cardiac disorders such as high-output failure caused by intrahepatic arteriovenous fistulae. Cardiac and hepatic disorders with joint etiology include infectious, metabolic, immune, vasculitic, and toxic disorders. We propose a practical approach to a diagnostic workup of combined cardiac and hepatic disorders based on recognizing the sequence of appearance of the cardiac and liver disease, presence of features of a multisystem disease, and presence of pathognomonic features. The evaluation of combined cardiac and hepatic disorders takes into consideration the expected benefit of treatment and the risks related to invasive procedures. Accordingly, investigations can be limited to ancillary tests for patients with congested liver and mild alterations of liver function tests, in cardiogenic ischemic hepatitis, patients with cardiac cirrhosis who are proposed for conservative treatment, and multisystem disease involving the heart and the liver. Conversely, comprehensive investigations are recommended when invasive therapeutic interventions are considered for the treatment of hepatopulmonary syndrome, portopulmonary hypertension, or arteriovenous fistulae. Conclusion: Classification of a patient to any of the 3 categories—heart diseases affecting the liver, liver diseases affecting the heart, and cardiac and hepatic disorders with joint etiology—permits the physician to narrow the span of the possible diagnoses and allows for a more simple workup. (Am Heart J 2000;140:111-20.)

Section snippets

Heart diseases affecting the liver

Hepatic complications of heart failure comprise a spectrum of combined cardiac and hepatic disorders (Table I).

. Associated cardiac and hepatic disorders

Heart diseases affecting the liver
 Mild alterations of liver function tests in heart failure
 Cardiogenic IH and its variants
 CLF and congestive (cardiac) cirrhosis
Liver diseases affecting the heart
 HPS in liver cirrhosis
 PPHTN in liver cirrhosis
 Pericardial effusion in cirrhosis
 Cirrhotic cardiomyopathy
 High-output failure caused by intrahepatic

Liver diseases affecting the heart

The resting cardiac output, left ventricular diastolic diameter, and mean velocity of left ventricular wall contraction may all be increased in patients with liver cirrhosis and are reversible after liver transplantation.1, 22 The hemodynamic consequences of liver disease, in the systemic and pulmonary circulation, hereafter called liver diseases affecting the heart, include: hepatopulmonary syndrome in cirrhosis, plexogenic pulmonary hypertension in cirrhosis, pericardial effusion in

Joint causes of hepatic and cardiac disorders

The heart and liver can both be targets of a common pathogenic process, which may be infectious, metabolic, immune, vasculitic, or toxic. Detailed inventory of these disorders is beyond the aim of this paper. Clues to their distinction from heart diseases affecting the liver and liver diseases affecting the heart may be found in the patient history and clinical examination. First, the simultaneous onset of a cardiac and liver disease during the course of an acute disorder may hint to a common

Diagnostic approach

The approach to the diagnosis of combined cardiac and hepatic disorders is based on recognizing the sequence of appearance of the cardiac and liver disease, presence of features of a multisystem disease, and presence of pathognomonic features. Consideration is given to the expected benefit of treatment and the risks related to invasive procedures in patients with advanced cardiac and liver disease. In most instances investigations can be limited to ancillary tests, as exemplified by mild

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    Reprint requests: Jochanan E. Naschitz, MD, Department of Internal Medicine A, Bnai Zion Medical Center, PO Box 4940, 31048 Haifa, Israel.

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