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01-09-2019 | Heart Failure | IM - COMMENTARY
The two congested failing giants: heart and liver
Published in: Internal and Emergency Medicine | Issue 6/2019
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Liver disease related to the heart includes acute liver injury due to the heart, i.e., myocardial infarction, sustained arrhythmia resulting in passive congestion of the liver, chronic passive liver congestion, and “cardiac cirrhosis” [1]. Causes of congestive heart failure appear in Fig. 1 [1]. Congestive heart failure occurs when patients with advanced heart failure experience persistent and severe symptoms interfering with daily life. Advanced congestive heart failure manifests with typical symptoms (Fig. 1) and, by definition, manifestations occur despite maximum evidence-based medical therapy of heart failure, and reversible causes addressed [2, 3]. Advanced heart failure has major socio-economic burden; patients experience recurrent hospitalization, and the risk of mortality increases with the frequency of re-hospitalization [4, 5]. We reported that addressing an intensive outpatient management program to patients with chronic heart failure has beneficial long-term effects on clinical parameters, and decreases hospitalization [6].
Fig. 1
Major etio-pathological, clinical, and laboratory changes with ongoing congestive heart failure and congestive hepatopathy. Causes of congestive heart failure and symptoms appear in the left upper yellow box. Major causes of hepatic injury, symptoms (pain), sign (jaundice), and blood abnormalities (ULN = upper normal limit) appear in the other boxes. In particular, hyperbilirubinemia [28] occurs in about 70% of the patients and correlates more with right atrial pressure than cardiac output [11]. Several factors contribute to elevated bilirubin [11], which is associated with increased risk of death in heart failure [28]. A subgroup of patients show increased serum aminotransferase levels [17] from ongoing ischemic hepatitis due to defective cardiac output [29]. Hypoalbuminemia occurs in 30% to 50% of the patients with advanced heart failure, and is associated with worse prognosis [30, 31]. Few factors contribute to this finding [32, 33]. Longstanding right heart failure and elevated central venous pressure can also evolve to liver cirrhosis [14], and symptoms include a dull pain in the right hypocondrium because of stretching of the liver capsule. Jaundice requires differential diagnosis from obstructive conditions. Liver cirrhosis will be associated with increasing portal hypertension [34] and hepatomegaly, more evident signs of right-heart failure, hepatojugular reflux and peripheral edema. If tricuspid regurgitation develops, the liver might become pulsatile, a sign which is loss with ongoing liver fibrosis and cirrhosis [33]. With ascites, the diagnostic paracentesis shows high total protein content ( > 2.5 g/dL, due to preserved synthetic function of the liver [10]) (colour figure online)
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