Key result
CAR-OLT and CAD-LT scores show modest discrimination for 1-year MACE after liver transplantation.
Why the study?
The real-world distribution of the CAR-OLT and CAD-LT risk scores across cardiac evaluation strategies and their performance for predicting post-transplant cardiovascular events in liver transplant candidates remained incompletely characterised.
Do the CAR-OLT and CAD-LT risk scores accurately predict one-year major adverse cardiovascular events (MACE) and differ between invasive and non-invasive cardiac evaluation strategies in adults undergoing orthotopic liver transplantation?
Cohort (n=637)
Do the CAR-OLT and CAD-LT risk scores accurately predict one-year major adverse cardiovascular events (MACE) and differ between invasive and non-invasive cardiac evaluation strategies in adults undergoing orthotopic liver transplantation?
Although CAR-OLT and CAD-LT scores are higher in liver transplant candidates selected for invasive cardiac evaluation, both scores demonstrate only modest discrimination for predicting one-year post-transplant MACE, underscoring the need for better transplant-specific risk stratification tools.
Background With an ageing population and rising metabolic comorbidities among liver transplant candidates, perioperative cardiovascular risk assessment has become increasingly important. Pre-transplant cardiac evaluation strategies before liver transplantation vary widely across centres. Risk stratification tools include the Cardiovascular Risk in Orthotopic Liver Transplantation (CAR-OLT) score (predicting perioperative major cardiovascular events) and Coronary Artery Disease in Liver Transplantation (CAD-LT) score (predicting significant coronary artery disease). These were developed to estimate perioperative cardiovascular risk, yet their real-world distribution across evaluation strategies and performance for predicting post-transplant events remain incompletely characterised. Purpose To compare CAR-OLT and CAD-LT score distributions between invasive (left heart catheterisation [LHC]-based) and non-invasive strategies and assess discrimination for one-year major adverse cardiovascular events (MACE). Methods We conducted a retrospective cohort study of 637 adults undergoing orthotopic liver transplantation between 1 January 2017 and 31 December 2024. Cardiac evaluation was categorised as LHC-based (invasive) or non-invasive, primarily stress testing. CAR-OLT and CAD-LT scores were calculated for all patients. One-year MACE was defined as myocardial infarction, new or decompensated heart failure, new or worsening pulmonary hypertension, cardiogenic shock, cardiac arrest, arrhythmia, cardiovascular death, or cerebrovascular accident. Score distributions were compared between strategies using non-parametric testing. Discrimination for one-year MACE was assessed using the area under the receiver operating characteristic curve (AUC). Results Patients undergoing LHC-based evaluation had higher baseline predicted risk. Median CAR-OLT score was 32.0 (IQR 25.0–39.2) in the invasive group versus 23.0 (IQR 16.0–31.0) in the non-invasive group (p<0.001). Median CAD-LT score was 12.0 (IQR 10.0–15.0) versus 8.0 (IQR 6.0–10.0), respectively (p<0.001). When evaluated for the prediction of one-year MACE, discrimination was modest. The AUC was 0.651 for CAR-OLT and 0.565 for CAD-LT, indicating limited ability of either model to differentiate patients who experienced events from those who did not. Conclusion CAR-OLT and CAD-LT scores were higher among patients selected for invasive pre-transplant cardiac evaluation, supporting the presence of risk-based selection. However, both models show only modest discrimination for one-year post-transplant MACE, suggesting a disconnect between preoperative risk prediction and post-transplant cardiovascular outcomes. These findings highlight the need for more accurate, transplant-specific risk stratification approaches to better guide pre-transplant evaluations and optimise outcomes.
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Huerta et al. (2026) conducted a cohort in Orthotopic liver transplantation candidates (n=637). Invasive cardiac evaluation (left heart catheterisation-based) and CAR-OLT/CAD-LT risk scores vs. Non-invasive cardiac evaluation (primarily stress testing) was evaluated on One-year major adverse cardiovascular events (MACE: myocardial infarction, new or decompensated heart failure, new or worsening pulmonary hypertension, cardiogenic shock, cardiac arrest, arrhythmia, cardiovascular death, or cerebrovascular accident) (AUC 0.651 (CAR-OLT), AUC 0.565 (CAD-LT), p=<0.001). CAR-OLT and CAD-LT scores were higher in invasive vs non-invasive groups (p<0.001) but showed modest discrimination for 1-year MACE (AUC 0.651 and 0.565).
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