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Cardiac Assessment of Liver Transplant Candidates - Summary

Cardiac Assessment of Liver Transplant Candidates - Summary - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular


INPATIENT Liver Transplant Candidate
Patient is assessed for cardiovascular risk factors
Patient undergoes EKG and TTE
Results of tests and risk factor assessment
discussed by Liver Transplant Team
Is pt considered
low risk?
No ischemic/coronary artery
disease evaluation warranted
YES
Is pt considered
moderate risk?
NO
Candidate for
calcium score with
CTA?
YES
Patient undergoes
calcium score with CTA
YES
Further evaluation at
discretion of liver transplant
team (e.g., stress echo)
NO
Pt is considered High Risk;
candidate for cardiac
catheterization
NO
Results
uninterpretable
or calcium score
≥ 400?
CCTA completed
Further evaluation at
discretion of
transplant team
Direct conversation from Liver/
Transplant attending with day’s
Interventional Cardiology Attending;
call Cath Charge Phone
(608-513-8562)
Order for catheterization placed
in HealthLink by Interventional
CardiologyTeam
Diagnostic pictures discussed by
Interventional Cardiology Attending
with Liver/Transplant Attending
Additional Potential Triggers for Cardiovascular
Medicine Consult:
Ejection Fraction < 50%
Resting TTE with regional wall motion abnormalities
(RWMA)
Moderate to severe valve disease
History of heart failure
History of arrthymias
Right ventricular (RV) dysfunction/RV dilation/
Pulmonary hypertension*
* If isolated abnormal ECHO findings, advance pulmonary
services should be consulted.
Test cannot be
completed;
catheterization may
be needed
Further evaluation
at discretion of
transplant team
YES
NO
Further evaluation/intervnetion at
discretion of liver transplant team
Candidate criteria for calcium score with CTA
Age < 65 years
eGFR > 40 ml/min/1.73m
2
HR < 90 (ok if on beta-blockers)
In normal sinus rhythm
Inpatient Liver Transplant Candidate Cardiac Assessment Algorithm
Cardiac Assessment of Liver Transplant Candidates – Adult
Target Population: Adult patients who are liver transplant candidates being assessed in the inpatient/outpatient setting
Full Guideline: Cardiac Assessment of Liver Transplant Candidates - Adult - Inpatient/Ambulatory clinical practice
guideline
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

OUTPATIENT
Liver transplant candidate
Diabetic?
Patient undergo:
12-Lead ECG
TTE
Coronary angiography with measurement
of left ventricular end diastolic pressure
NO stress test
Any other
cardiovascular risk
factors?
Is patient
≥ 40 years?
Patient undergo:
12-Lead ECG
TTE
Stress
echocardiography*
* Dobutamine stress
testing if cannot exercise or
has underlying LBBB
Able to achieve
≥ 4 METS?
Cardiovascular risk factors
Hypertension/history of
hypertension or Left ventricular
hypertrophy
Smoker or any history of smoking
Hyperlipidemia/dyslipidemia
Family history of Coronary Artery
Disease (i.e., 1
st
degree male
relative ≤ 55 years or 1
st
degree
female relative ≤ 65 years)
Peripheral artery disease
Patient undergo:
12-Lead ECG
TTE
Stress test NOT required
Patient undergo:
12-Lead ECG
TTE
Stress echocardiography*
* Dobutamine stress testing if cannot
exercise or has underlying LBBB
Patient undergo:
12-Lead ECG
TTE
Stress* echocardiography
* Dobutamine stre ss testing if
cannot exerci se or has
underlying LBBB
Candidate for
calcium score
with CTA?
NO
YES
NO
Patient
undergoes
calcium score
with CTA
Results
uninterpretable
or calcium score
≥ 400?
CTA completed
Risk assessment and
test results discussed
by transplant team
Test cannot be
completed;
Patient may
require
catheterization
Further
intervention
and test results
to be discussed
by transplant
team
NO
NO
NO
YES
YES
Pt have ≥ 2
risk factors?
NO
YES
Calcium score with
Computed tomographic
ateriography (CTA) candidate
criteria:
Age < 65 years
eGFR > 40 ml/min/1.73m
2
Heart rate < 90
In normal sinus rhythm
YES
YES
Outpatient Liver Transplant Candidate Cardiac Assessment Algorithm
Established CAD?
NO
Cardiology consultation
preferably with local
established cardiologist; if not
feasible or 2
nd
opinion needed,
consult UW Cardiology
YES
Additional Potential Triggers for Cardiovascular
Medicine Consult:
Ejection Fraction < 50%
Resting TTE with regional wall motion
abnormalities (RWMA)
Moderate to severe valve disease
History of heart failure
History of arrthymias
Right ventricular (RV) dysfunction/RV dilation/
Pulmonary hypertension*
* If isolated abnormal ECHO findings, advance
pulmonary services should be consulted.
NO
YES
Patients who may have cardiac
catheterization ordered directly
by Liver Transplant Team:
Patients with abnormal stress
tests undergoing liver
transplant
Diabetic patients or patients
with ≥ 2 risk factors with
calcium score > 400 or
uninterpretable results
Patients with excessive risk
of cardiac complications and
invasive cath will impact
transplant candidacy
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org