Cirrhotic cardiomyopathy and beyond: Underscoring the interaction between the liver and the heart

The review by Liu et al elegantly summarizes the pathophysiology and clinical burden of cirrhotic cardiomyopathy (CCM).(1Liu H. Naser J.A. Lin G. et al.Cardiomyopathy in cirrhosis: From pathophysiology to clinical care.JHEP Reports. 2024; 6100911Abstract Full Text Full Text PDF Scopus (3) Google Scholar) We aim to highlight the complex and dynamic interactions between the liver and the heart. First, CCM can be considered end-stage cardiomyopathy with multiple causes, including coronary artery disease (CAD), and various liver diseases are associated with CAD. Notably, metabolic dysfunction-associated steatotic liver disease (MASLD) and primary biliary cholangitis (PBC) are associated with obstructive and nonobstructive coronary artery disease, respectively, requiring different clinical management and prevention strategies. Patients with MASLD have different degrees of dysmetabolism and insulin resistance, which translate into an increased risk of obstructive coronary artery disease and atherosclerosis.(2Zhang Z. Zheng M. Lei H. et al.A clinical study of the correlation between metabolic-associated fatty liver disease and coronary plaque pattern.Sci Rep. 2023; 13: 7224Crossref Scopus (2) Google Scholar) The progression of MASLD towards compensated advanced chronic liver disease (cACLD) is also strictly associated with cardiovascular events.(3Bischoff SC, Barazzoni R, Busetto L, et al. European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline. Clin Nutr. 022;41(10):2364-2405.Google Scholar) Primary biliary cholangitis is characterized by an increased microvascular resistance and reduced coronary artery flow reserve.(4Cazzagon N. Dal Lin C. Famoso G. et al.Coronary flow reserve in patients with primary biliary cholangitis.Digestive and Liver Disease. 2019; 51: 542-548Abstract Full Text Full Text PDF Google Scholar) Additionally, these patients are more likely to suffer from autonomic dysfunction, a condition associated with an increased risk of cardiovascular mortality, and a reduced tolerability to beta-blockers.(5Jopson L. Dyson J.K. Jones D.E.J. Understanding and Treating Fatigue in Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis.Clinics in Liver Disease. 2016; 20: 131-142Abstract Full Text Full Text PDF PubMed Google Scholar) Efforts should be directed towards identifying coronary artery disease in the early stages, activating tailored strategies against obstructive or nonobstructive coronary artery disease, and possibly mitigating the risk of developing CCM. Second, we aim to underscore the intricate interplay between the liver and the heart along the trajectories of the natural history of liver cirrhosis. The revised Baveno VII classification of liver cirrhosis, including compensated advanced chronic liver disease (cACLD), non-acute decompensation, stable decompensated cirrhosis, unstable decompensated cirrhosis, pre-acute-on-chronic liver failure, and acute-on-chronic liver failure (ACLF), better aligns with the dynamicity of hepatic insufficiency and portal hypertension.(6Mendizabal M. Cançado G.G.L. Albillos A. Evolving portal hypertension through Baveno VII recommendations.Ann Hepatol. 2024; 29101180Crossref Scopus (0) Google Scholar) A comparison of the natural history of cirrhosis and decompensated heart failure has become more straightforward with this classification, as both conditions are characterized by phases of decompensation and shared triggers, such as ischemia, infection, or alcohol consumption. Given the potential pathohistological association and epidemiological burden of cardiovascular diseases, dedicated studies are needed to evaluate the role of the heart as a potential trigger for ACLF. Finally, considering the high mortality risk associated with both conditions, a multidisciplinary and holistic approach are imperative in managing patients with CCM.(7Xu M. Chen Y. Artru F. Acute decompensation ofcirrhosis versus acute‐on‐chronic liver failure: What are the clinical implications?.United European Gastroenterol J. 2024; 12: 194-202Crossref Scopus (0) Google Scholar, 8McDonagh T.A. Metra M. et al.2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC.European J of Heart Fail. 2024; 26: 5-17Google Scholar) In conclusion, the review by Liu et al. serves as a comprehensive exploration of cirrhotic cardiomyopathy, we underline the importance of a tailored cardiovascular prevention, and propose further studies to better understand the complex interplay between decompensated heart failure and liver failure. All authors have no relevant conflicts to disclose. conceptualization and draft of the letter: GL and VC. Critical revision for important intellectual content: SC and LR. No funding was obtained for this research.