European Journal of Cardiovascular Medicine

While chronic alcohol abuse is a well-established cause of cirrhosis, recent lifestyle changes have led to an increased incidence of cirrhosis related to nonalcoholic steatohepatitis (NASH).1 "Cirrhotic cardiomyopathy" is a recently identified condition marked by systolic dysfunction during stress,               diastolic dysfunction caused            by impaired diastolic relaxation, and electrophysiological abnormalities, all occurring in the absence of any known cardiac disease.2 Patients with cirrhotic cardiomyopathy are prone to developing overt heart failure under stress conditions such as infections or ascites. When heart failure becomes apparent, the treatment approach should mirror that of heart failure from non-cirrhotic causes. Therefore, clinicians should maintain a high level of suspicion for cirrhotic cardiomyopathy in all cirrhotic patients who meet the diagnostic criteria, enabling early and effective treatment of potential heart failure

in these individuals.3 Cirrhotic cardiomyopathy is a recently recognized condition associated with cirrhosis, characterized by systolic incompetence in the presence of diastolic dysfunction and electrophysiological abnormalities, despite the absence of any known cardiac disease. Typically, systolic function in individuals with cirrhosis appears normal at rest; however, systolic incompetence becomes evident under stress, whether physical, pharmacological, or during conditions that demand increased cardiac output, such as bacterial infections.4

Diagnosis of cirrhotic cardiomyopathy involves a combination of electrocardiography, 2D echocardiography, and biomarkers like brain natriuretic factor. The criteria for diagnosis include evidence of systolic dysfunction, such as a resting ejection fraction (EF) below 55% or a blunted increase in cardiac output during exercise or pharmacological challenge. Diastolic dysfunction is indicated by an early to late ventricular filling phase ratio (E/A ratio) of less than 1.0, prolonged deceleration time, or prolonged isovolumetric relaxation time.5 Supportive criteria encompass a range of electrophysiological abnormalities, including electromechanical uncoupling, abnormal chronotropic response, prolonged QTc interval, and structural changes such as an enlarged left atrium or increased myocardial mass.6 Additionally, elevated levels of biomarkers like brain natriuretic peptide (BNP), pro-BNP, and troponin I can also support the diagnosis. Importantly, not all these features are necessary for a definitive diagnosis of cirrhotic cardiomyopathy.2

This cross-sectional study was conducted at Dr. PSIMS & RF Hospital, involving 50 consecutive patients diagnosed with cirrhosis. Each patient underwent a comprehensive clinical examination and a series of detailed investigations. The patients were categorized based on the severity of their liver cirrhosis using the Child-Pugh score (dividing them into Child's Classes A, B, and C) and the MELD score.7 All patients underwent QTc interval assessment and 2D echocardiography. The presence of cirrhotic cardiomyopathy was evaluated according to the criteria established by the 2005 World Congress of Gastroenterology in Montreal.8 The study results were then analyzed and correlated with the severity of liver cirrhosis.

The inclusion criteria for the study consisted of hospitalized patients diagnosed with liver cirrhosis, with or without ascites. The diagnosis of cirrhosis was based on clear clinical evidence, including the presence of chronic liver disease, jaundice, ascites, esophageal varices, abnormal liver function tests, and ultrasonographic findings consistent with cirrhosis, such as diffuse liver parenchymal alterations, nodular transformation, and signs of portal hypertension. The exclusion criteria included patients under 18 years of age, those with chronic obstructive pulmonary disease (COPD), and patients with co-existing intrinsic heart disease.

Statistical analysis was performed using SPSS version 21. Descriptive statistics were presented as percentages and mean with standard deviation (SD). To assess significance, various statistical tests were employed, including the Chi-square test, independent t-test, ANOVA, and Pearson correlation. A p-value of less than 0.05 was considered to indicate statistical significance.

The study group had an average age of 51.45 years, with a range of about 14 years. Most participants were male (62%), while 38% were female. Nearly half (48%) had a history of alcoholism. Hepatomegaly was observed in 20% of the group, and more than half (52%) had splenomegaly. A small proportion had massive ascites (8%), and 42% experienced mild to moderate ascites. In terms of viral infections, 16% were positive for HBsAg, and 6% were positive for HCV.

Table 1: Baseline characteristics

The study participants had varying levels of liver disease severity. According to the Child-Pugh classification, 44% were in Class A (mild), 22% in Class B, and 34% in Class C (severe). MELD scores showed that 28% had scores of 9 or less, 30% had scores between 10 and 19, 22% had scores from 20 to 29, and 20% had scores of 30 or higher. [Table No.2]

Table 2: Child – Pugh & MELD scores

Patients with QTc intervals ≤ 440 ms are more likely to have better liver function, with 65.5% in Child-Pugh Class A and 37.9% having MELD scores ≤ 9. In contrast, those with QTc intervals > 440 ms often have more severe liver impairment, with 71.4% in Child-Pugh Class C and 42.9% having MELD scores ≥ 30. These differences were also found to be statistically significant

 (p<0.05) [Table No.3].

Table 3: Comparison of QTc intervals with Child – Pugh and MELD scores

Patients with ejection fractions > 55% were found to have better liver function, with 73.7% in Child-Pugh Class A and 47.4% having MELD scores ≤ 9. In contrast, those with ejection fractions ≤ 55% often have more severe liver impairment, with 51.6% in Child-Pugh Class C and 29.0% having MELD scores ≥ 30, with a significant difference (p<0.05). [Table No.4]

Table 4: Comparison of Ejection fraction with Child – Pugh and MELD scores

Cardiac parameters across Child-Pugh Score classes show significant differences in right atrial size (RA Size), left atrial size (LA Size), and ejection fraction (EF). Patients in Child-Pugh Class C have a larger average RA Size (30.68 mm) and LA Size (29.60 mm) compared to those in Class A and B, with significant differences noted (p = 0.010 and p = 0.019, respectively). Ejection fraction is also significantly lower in Class C (0.51) compared to Classes A (0.59) and B (0.56) (p < 0.001). However, left ventricular end-diastolic dimension (LVEDD) does not show significant variation across the Child-Pugh classes (p = 0.142).

Table 5: Mean Cardiac Parameters across Child-Pugh Score Classes

The study included patients aged between 30 and 81 years, with an average age of 58.96 ± 10.79 years. This mean age is higher compared to findings by Bhattacharyya M, et al.9 (45.8 ± 10 years) and Maskey R et al.10 (49.06 ± 11.27 years) but lower than the mean age reported by Bustíos C et al.11 (63.4 years). Among the 50 patients, 40% had alcoholic cirrhosis, 16% had hepatitis B-related cirrhosis, 6% had hepatitis C, 6.94% had cirrhosis from both alcoholism and hepatitis B, and 1.39% had both alcoholism and hepatitis C. Alcoholics accounted for 42% of

patients, with a significant predominance among males (75%) compared to females (none). This prevalence aligns with cultural practices in India, where female alcoholism is less common.

Clinical manifestations included ascites in 50% of patients, with 8% experiencing massive ascites and 42% having mild to moderate ascites. Additionally, 20% had hepatomegaly, and 52% had splenomegaly at presentation.

Regarding liver disease severity, 44% of patients were classified as Child-Pugh Class A, 22% as Class B, and 34% as Class C. This distribution differs from findings reported by Hajiani E et al,.12 who found 19% in Class A, 30% in Class B, and 51% in Class C. Similarly, studies by by Bhattacharyya M, et al.9and Maskey R et al.10 et al. reported that over 50% of patients were in Child-Pugh Class C, indicating a greater prevalence of advanced disease. Furthermore, research conducted by Onyekwere CA et al.13 in revealed that 19% of patients were in Class A, 61% in Class B, and 20% in Class C. These variations across studies could be due to differences in when patients present to the hospital and the stage of liver disease at diagnosis.

The analysis showed that 58% of patients had a normal QTc interval, while 42% had a prolonged QTc interval. Prolonged QTc was more prevalent in patients with more severe liver cirrhosis (Class C) and higher MELD scores. The mean QTc interval increased with the severity of liver disease, and this correlation was statistically significant (p < 0.001). Findings align with studies by Bernardi M,et al.,14 Natig Gassanov et al.,2 and Naik K, et al.,15 which also reported a significant association between QTc prolongation and the severity of liver cirrhosis.

The study shows significant differences in cardiac parameters across Child-Pugh classes, with marked variations in right atrial size (RA Size), left atrial size (LA Size), and ejection fraction (EF).RA Size and LA Size were found to be largest in Child-Pugh Class C, reflecting an adaptation of cardiac hemodynamics to more severe liver disease. Conversely, EF was lowest in this group, indicating a decline in cardiac function as liver disease progresses. Notably, left ventricular end-diastolic dimension (LVEDD) did not show significant variation across the Child-Pugh classes. These findings align with a study by Dhangar V, et al.,16 which found that cirrhotic patients had significantly larger right and left atrial sizes compared to controls, although

LVEDD (39.8 mm) and EF (63.12%) showed no significant differences. Similarly, Naik K, et al.,15 et al. reported larger diameters for RA and LA (28.1 ± 1.31 mm and 35.8 ± 4.55 mm, respectively), with no differences in LVEDD (40.7 ± 5.9 mm) and EF (64.16 ± 10.495%). These observations suggest that atrial dilation may serve as an adaptive response to altered cardiac hemodynamics associated with liver cirrhosis.

The slightly lower ejection fraction (55.52%) observed in the current study compared to previous research might reflect differences in the extent of cardiac impairment related to liver disease or variations in study populations. This finding highlights the effect of liver cirrhosis on cardiac function and underscores the necessity for further research into how liver disease severity influences cardiac parameters.

In conclusion, this study reveals that liver cirrhosis predominantly affects males with a mean age of 58.96 years and identifies chronic alcohol abuse as a significant contributing factor. Clinical presentations include ascites, splenomegaly, and hepatomegaly, with liver disease severity distributed across Child-Pugh Classes A, B, and C. The mean MELD score is 18.33, with higher scores observed in males compared to females. Significant cardiac findings include prolonged QTc intervals in 42% of patients, correlated strongly with both Child-Pugh and MELD scores. Ejection fraction for Class A patients is 0.59, and systolic dysfunction shows a significant correlation with disease severity. These findings highlight the significant cardiac effects of liver cirrhosis, emphasizing the importance of continuous monitoring and management of cardiac function in affected patients.

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