Detection and treatment of coronary artery disease in liver transplant candidates

Patients with end-stage liver disease and coronary artery disease (CAD) being considered for orthotopic liver transplantation (OLT) present a difficult dilemma. The availability of multiple screening tests and newer treatment options for CAD prompted this review. Recent data suggest that the prevalence of CAD in patients with cirrhosis is much greater than previously believed and likely mirrors or exceeds the prevalence rate in the healthy population. The morbidity and mortality of patients with CAD who undergo OLT without treatment are unacceptably high, making identification of patients with CAD before OLT an important consideration. Patients with documented CAD or major clinical predictors of CAD should undergo cardiac catheterization before OLT. Those with advanced CAD not amenable to interventional therapy or with poor cardiac function are not candidates for OLT. Dobutamine stress echocardiogram appears to be an excellent means of screening patients with intermediate or minor clinical predictors of CAD before OLT. Patients found to have mild or moderate CAD should be aggressively treated medically and, if necessary and feasible based on hepatic reserve, by percutaneous or, less likely, surgical intervention pre-OLT to correct obstructive coronary lesions. Prospective studies regarding optimal screening strategies for the presence of CAD and the indications, timing, and outcomes of interventional therapy in patients with advanced cirrhosis are lacking and much needed.