Factors Associated With Major Adverse Cardiovascular Events After Liver Transplantation Among a National Sample

Abstract

Assessment of major adverse cardiovascular events (MACE) after liver transplantation (LT) has been limited by the lack of a multicenter study with detailed clinical information. An integrated database linking information from the University HealthSystem Consortium and the Organ Procurement and Transplant Network was analyzed using multivariate Poisson regression to assess factors associated with 30- and 90-day MACE after LT (February 2002 to December 2012). MACE was defined as myocardial infarction (MI), heart failure (HF), atrial fibrillation (AF), cardiac arrest, pulmonary embolism, and/or stroke. Of 32 810 recipients, MACE hospitalizations occurred in 8% and 11% of patients at 30 and 90 days, respectively. Recipients with MACE were older and more likely to have a history of nonalcoholic steatohepatitis (NASH), alcoholic cirrhosis, MI, HF, stroke, AF and pulmonary and chronic renal disease than those without MACE. In multivariable analysis, age >65 years (incidence rate ratio [IRR] 2.8, 95% confidence interval [95% CI] 1.8-4.4), alcoholic cirrhosis (IRR 1.6, 95% CI 1.2-2.2), NASH (IRR 1.6, 95% CI 1.1-2.4), pre-LT creatinine (IRR 1.1, 95% CI 1.04-1.2), baseline AF (IRR 6.9, 95% CI 5.0-9.6) and stroke (IRR 6.3, 95% CI 1.6-25.4) were independently associated with MACE. MACE was associated with lower 1-year survival after LT (79% vs. 88%, p < 0.0001). In a national database, MACE occurred in 11% of LT recipients and had a negative impact on survival. Pre-LT AF and stroke substantially increase the risk of MACE, highlighting potentially high-risk LT candidates.

Keywords: Organ Procurement and Transplantation Network (OPTN); cardiovascular disease; clinical research/practice; comorbidities; complication: medical/metabolic; health services and outcomes research; liver transplantation/hepatology; risk assessment/risk stratification.

Figure 1. Distribution of early MACE after liver transplantation

Among 32,810 LT recipients, 4,440 were admitted within 30 days and 6,095 within 90 days of LT. MACE occurred in 368 (8%) and 474 (11%) patients at 30 and 90 days, respectively. The most common cause of an early (within 90-days of LT) MACE was atrial fibrillation followed by heart failure and pulmonary embolism. Distribution was similar for 30-day MACE. Abbreviations: MACE, major adverse cardiovascular event; LT, liver transplantation; MI, myocardial infarction.

Figure 2. Long-term recipient survival in those with and without a MACE after liver transplantation

Cox proportional hazard survival analysis adjusted for recipient age, gender, race, body mass index, education level, insurance status, MELD score, indication for transplant, donor risk index and cold ischemic time. 30-day and 90-day MACE were associated with lower long-term recipient survival (HR=1.62, 95% CI: 1.36–1.92 for 30-day MACE; HR=1.54 95% CI: 1.32–1.79 for 90-day MACE). Patients were censored at time of death or date of last follow up. Abbreviations: MACE, major adverse cardiovascular event