Letter: Is Routine ECG Monitoring Redundant During Terlipressin Therapy in HRS ‐ AKI ?

We read with great interest the study by Bajaj et al., which offers a valuable pooled analysis of arrhythmias in patients with hepatorenal syndrome–acute kidney injury (HRS-AKI) treated with terlipressin. The authors are to be commended for assembling the largest prospective dataset on this topic to date and for addressing an important clinical question regarding the cardiac safety of vasopressor use in this fragile population [1]. That said, several points warrant closer scrutiny. The incidence of bradycardia was notably higher in the terlipressin group (6.3%) compared to placebo (0.8%). Although these events were often classified as “severe,” the report provides limited insight into their clinical impact—such as symptoms, haemodynamic consequences, or delays in treatment response. In patients with advanced cirrhosis, even modest reductions in heart rate may impair coronary or renal perfusion. Thus, the absence of treatment discontinuation alone may not be sufficient to declare these events clinically irrelevant. The suggestion that routine ECG monitoring may not be necessary also merits caution. The trial population excluded patients with significant cardiovascular disease, and no subgroup analysis was conducted among individuals with heightened arrhythmic risk (e.g., elderly, baseline arrhythmias, hyponatremia, advanced ACLF). These omissions limit the generalisability of the findings and may underrepresent real-world risk [2]. Moreover, the assessment of QT prolongation was limited, with only partial ECG data reported from one trial and no integration of electrolyte abnormalities or baseline QTc values. Given the established association between cirrhosis and QT prolongation, and the known predictive value of QTc prolongation in cirrhotic cardiomyopathy, a more comprehensive analysis would strengthen the interpretation of cardiac safety [3, 4]. Factors such as hypoalbuminaemia and hyponatraemia, which are common in this population, have been independently linked to QT prolongation and arrhythmic risk [5]. Lastly, while the study focuses on event incidence, it does not examine whether arrhythmias influenced meaningful clinical outcomes such as HRS reversal, ICU admission, or dialysis requirement. A more integrated view of cardiovascular events in the context of organ failure trajectories would enhance the translational relevance of the findings. We believe that these clarifications could help refine future safety guidance and support patient-centred risk stratification strategies in the use of terlipressin. Xing Wang: conceptualization, investigation, writing – original draft, methodology, visualization, writing – review and editing, formal analysis. The author has nothing to declare. The author has nothing to report. The author declares no conflicts of interest. This article is linked to Bajaj et al paper. To view this article, visit https://doi.org/10.1111/apt.70297. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.