Systemic Consequences of Pulmonary Hypertension and Right-Sided Heart Failure | Circulation
What To Know About Cardiac Cirrhosis
Cardiac cirrhosis is a serious liver disorder that can be triggered by cardiac (heart) circulation issues such as heart failure. The key to managing it is to effectively treat the underlying heart condition.
The term "cardiac cirrhosis" refers to any of the liver disorders that can develop when heart problems lead to congestion or fluid buildup in your liver. Your liver relies on healthy circulation to function properly. When a heart condition reduces blood flow, serious liver problems can occur.
Treating cardiac cirrhosis involves managing the heart problem at the root of the liver disorder. If you have cardiac cirrhosis, your outlook will depend largely on the health and status of your heart.
This article takes a closer look at the symptoms, causes, diagnosis, and treatment of cardiac cirrhosis.
Heart health and liver health are linked. If you have liver disease, it means toxins are not being filtered out of your blood effectively. This can ultimately harm your heart and other organs.
If your heart isn't consistently pumping oxygenated and nutrient-rich blood to your liver, your liver can develop problems such as cardiac cirrhosis.
A diagnosis of cardiac cirrhosis, also known as congestive hepatopathy, means that the pressure is increasing in the veins running through your liver. This is usually due to heart failure and the weakening of your heart's ability to pump blood throughout your body.
Problems with the veins in your liver can cause fluid buildup within your liver. This, in turn, results in scarring and injury to hepatocytes — the cells that make up most of your liver tissue. In time, this can negatively affect your liver's many functions.
If you've received a diagnosis of heart failure or another serious heart condition, a healthcare professional should also evaluate you for other complications, including liver dysfunction.
This involves a physical examination to check for liver swelling or tenderness and a review of any possible symptoms, such as jaundice, abdominal pain, or changes in the appearance of stool or urine.
The other important diagnostic tool is a blood test that checks your liver enzyme levels. Elevated levels can indicate some type of disorder. If it appears that you may have some liver dysfunction, your doctor may order one or more imaging tests. Standard liver imaging includes:
A 2020 study suggests that cardiac cirrhosis is largely underdiagnosed, in part because standard imaging scans can miss the condition.
The researchers suggest that doctors consider performing a liver biopsy, in which a small portion of liver tissue is removed and analyzed in a lab. This is especially helpful in cases where a heart transplant may be necessary to treat severe heart failure.
Treatment for cardiac cirrhosis involves addressing the underlying cause of the right sided heart failure. The American Heart Association provides the following guidelines for assessing and managing potential causes of right sided heart failure:
Directed medications that may be used for right sided and left sided heart failure include:
A 2020 review on the "heart-liver axis" recommends diuretics for people with heart failure and cardiac cirrhosis. Diuretics help prevent fluid retention by reducing fluid levels throughout your body. Diuretics also help with symptom management.
If you have cardiac cirrhosis, you should also try to adopt heart- and liver-healthy lifestyle habits, including:
Liver dysfunction may be reversible if healthy heart function can be restored.
A 2016 review suggests that liver disease resulting from cardiac cirrhosis is rarely the factor that affects survival. Instead, the severity of heart failure or another cardiac condition has the greatest impact on long-term health and mortality.
Improvements in the management of heart failure have led to reduced mortality rates.
According to a 2017 review, the 1-year survival rate is 80% to 90% after diagnosis, while the 5-year survival rate is closer to 50% to 60%. If heart function does not improve or worsens over time, the liver dysfunction may be just as serious as the heart disease and could complicate treatment of both conditions.
Heart Failure Treatment And Diagnosis
Heart failure means that your heart isn't working as efficiently as it should. If your doctor thinks you might have heart failure, they will talk with you about your medical history and do a physical exam and tests.
Medical history: To get your medical history, your doctor will want to know if:
Physical exam for heart failure: Your doctor will look for signs of heart failure as well as other illnesses that may have weakened your heart. They will:
They'll also look at your appearance while you sit, do mild activity, and lie flat. People with mild or moderate heart failure may appear comfortable at rest, but when active, they often become short of breath. Those with heart failure may be uncomfortable if they lie flat for a few minutes.
Your doctor may check for fluid in your lungs with a stethoscope. People with heart failure may also have neck veins that are larger than normal, swelling of the legs or belly, or an enlarged liver.
Tests that your doctor might order to diagnose heart failure include:
Blood tests to check for anemia, thyroid problems, and high cholesterol, conditions that can be related to heart failure. There is also a blood test for B-type natriuretic peptide (BNP), which can indicate active heart failure.
Urine tests to look for signs of kidney problems or diabetes, a cause of heart disease
Electrocardiogram (ECG or EKG) to assess the heart rate and rhythm. This test can often detect heart disease, heart attack, an enlarged heart, or abnormal heart rhythms that may cause heart failure.
Chest X-ray. You may get this done to see if your heart is enlarged and if your lungs are congested with fluid.
Echocardiogram. This is an ultrasound test to check on heart muscle function, see how well the heart is pumping, and detect problems with the heart valves that may cause heart failure. It can also measure ejection fraction (EF). EF is a measure of how much blood is pumped out of the heart with each beat. A normal EF is generally greater than 55%, which means that over half of the blood volume in the heart's main pumping chamber is pumped out with each beat.
Radionuclide ventriculography. This shows the pumping function of the left and right ventricles (the heart's large pumping chambers) during heart contractions. This test can also measure EF. Rarely done by itself, you may get it as part of an exercise stress test.
Cardiac MRI. The goal is to distinguish scars from normal tissue and abnormalities in the heart muscle. Cardiac MRI can also measure EF. This test is generally available only in large heart centers and is rarely used as a first step in heart disease diagnosis.
Exercise stress test. This is an EKG done while you either walk on a treadmill, cycle on a stationary bike, or use medications to simulate exercise. This test lets your doctor check for any heart function problems brought on by exercise, which may indicate coronary artery disease.
Your doctor may also do more invasive tests, such as cardiac catheterization, to directly visualize the heart's chambers. This test can determine if coronary artery disease is present and can also measure EF.
CT coronary angiogram. It uses an X-ray and a contrast dye to see if you have coronary artery disease. Your doctor can view images in 3D, which lets them see blockages in your arteries.
Myocardial biopsy. In this test, your doctor puts a small, flexible biopsy catheter into a vein in your neck or groin, and takes a small piece of your heart muscle. This test can diagnose certain types of heart muscle diseases that cause heart failure.
Treatment of heart failure focuses on slowing or reversing its progression. The earlier treatment starts, the better.
After making the diagnosis, your doctor will recommend lifestyle changes. They may recommend that you reach and maintain a healthy weight, become more active, cut down on sodium and fluids, and avoid alcohol. If you smoke or chew tobacco, you'll be advised to stop. You'll work with your doctor to find the right balance of rest and activity, as mobility is important for blood circulation. You will also need to weigh yourself daily and record your weight to help flag any fluid retention.
Your doctor will also prescribe several medications to manage your heart failure or the problem that caused the heart failure. Drugs used to treat heart failure, often in combination, include:
Diuretics or water pills can help reduce symptoms of heart failure or keep them from getting worse. For example, they may help make breathing easier by helping pull fluid out of the lungs. A diuretic makes you urinate a lot, especially when you first start taking it. The diuretics you're most likely to be started on for heart failure include bumetanide (Bumex), furosemide (Lasix), and torsemide (Demadex).
Your doctor may also prescribe a thiazide diuretic like chlorothiazide (Diuril) or metolazone (Zaroxolyn). Another option is a mineralocorticoid receptor antagonist like eplerenone (Inspra) and spironolactone (Aldactone) that removes extra salt and fluid and holds onto potassium.
Potassiumsupplementsreplace the potassium that may be lost because the diuretics make you urinate more.
ACE inhibitors have several benefits for people with heart failure. These medications are vasodilators, which means that they expand blood vessels and increase blood flow, thus helping the heart pump more efficiently. ACE inhibitors are important heart failure drugs since they have been shown to help most people with heart failure live longer and with a better quality of life. ACE inhibitors include: captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), quinapril (Accupril), ramipril (Altace) and trandolapril (Mavik).
Angiotensin receptor blockers (ARBs) work in similar ways as ACE inhibitors. They are prescribed when people get side effects from ACE inhibitors, such a cough or high potassium levels. Examples of ARBs include: candesartan (Atacand), losartan (Cozaar), and valsartan (Diovan).
Angiotensin receptor-neprilysin Inhibitors (ARNs) combine a neprilysin inhibitor and an ARB. Entresto (sacubitril/valsartan) and are superior replacements to ACE inhibitors or other ARBs.
Beta-blockers can improve the heart's ability to relax, and curb production of harmful hormones made by the body in response to heart failure. Beta-blockers used to treat heart failure include carvedilol (Coreg) and metoprolol succinate (Lopressor).
Digoxin, sold under the brand name Lanoxin, may improve heart pumping function and control certain heart rhythm problems. Digoxin is an older medication and not used as often as in the past, because many of the newer drugs appear to have more profound effects on symptom control and overall outcome. But it may still be a reasonable add-on for people whose symptoms don't improve with diuretics and ACE inhibitors.
Selective sinus node inhibitors is a class of drug that targets a specific area of the heart, the sinoatrial pacemaker. Ivabradine (Corlanor) lowers the heart rate and helps the lower left ventricle contract more efficiently.
Soluble guanylate cyclase (sGC) stimulators help relax and widen the blood vessels so blood can flow more easily. The drug vericiguat (Verquvo) can be prescribed for people with chronic heart failure who have been hospitalized or need IV diuretics. It helps reduce the risk of dying and further hospitalization.
Some of these drugs may cause unwanted side effects. Tell your doctor about any problems you have. Don't stop or cut down on the dose of any prescribed medication unless your doctor tells you to.
In some cases, when drugs don't improve heart function enough or cannot be tolerated, you may need surgery or another procedure. Doctors recommend surgery for several major reasons: to correct certain problems that cause heart failure (such as coronary artery bypass graft surgery), to repair or replace valves, to implant devices (such as an intra-aortic balloon pump, specialized pacemakers, ICDs, or ventricular-assist devices) to help the heart pump, or to transplant a new heart. Heart transplants are used to treat severe congestive heart failure.
If the cost of any medications is a problem for you, tell your doctor. There may be lower-priced generic medications or other options.
Common Symptoms Of Congestive Heart Failure And How It's Diagnosed
To determine if you have heart failure, a doctor will take your complete medical history and conduct a physical examination.
You may also need some of the following diagnostic procedures:
Blood Test By taking a blood sample, your doctor can have your kidney, liver, and thyroid function checked for indicators of other diseases that affect the heart or are affected by the function of the heart. Your doctor may perform a blood test that checks for a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP) to help in diagnosing worsening heart failure.
Chest X-Ray A chest X-ray produces images of your internal tissues, bones, and organs so that your doctor can rule out conditions other than heart failure that may explain your symptoms. If you have heart failure, X-ray results may show an enlarged heart and signs of fluid buildup in your lungs.
Echocardiogram An echocardiogram uses sound waves to create pictures of the heart. This test helps your doctor see the shape of your heart and how well it's pumping. Heart chamber size and function, as well as valve structure, can be detected by an echocardiogram.
An echocardiogram can also distinguish systolic heart failure from diastolic heart failure. Your doctor can look for valve problems, evidence of previous heart attacks, and other heart abnormalities that may be causing heart failure.
Electrocardiogram (ECG or EKG) During an electrocardiogram, wires are taped to your body to create a tracing of your heart's electrical rhythm. An EKG allows your doctor to diagnose heart rhythm problems and damage to your heart from a previous heart attack that may be the cause of your heart failure.
Stress Test This test is used to measure how your heart and blood vessels respond to exertion. It can help doctors detect if you have significant coronary artery disease and determine how well your body is responding to your heart's decreased capacity to pump.
There are a few ways to do a stress test:
Your doctor may order a nuclear stress test or a stress echocardiogram, which show images of your heart while you're exercising.
Magnetic Resonance Imaging (MRI) During a cardiac MRI, you lie on table that slides into a long tubelike machine. The machine creates a strong magnetic field around you. Radio waves are directed at the area of the body to be imaged. An MRI can show your doctor the structure of your heart, if the heart has been damaged from a heart attack, or if the heart has scar tissue.
Coronary Angiogram Also called cardiac catheterization, this test involves the insertion of a small tube, called a catheter, into a blood vessel in the upper thigh or arm. The catheter is guided through the aorta and into the coronary arteries. A dye is injected to make the arteries visible and allow doctors to see if there are any blockages.
Radionuclide Ventriculography or Radionuclide Angiography (MUGA Scan) During this test, radioactive substances called radionuclides are injected into your bloodstream with a shot or through an IV. You are then placed under a gamma camera, which captures images of your heart as it beats.
This test allows your doctor to see how well your heart muscle is supplied with blood, how well your heart's chambers are working, and whether part of the heart has been damaged by a heart attack.[2]
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Additional reporting by Ashley Welch
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