Dobutamine Stress Echo for Liver Transplant: High Specificity, Low Sensitivity for Pre-Transplant Cardiac Risk, June 2025, IHJ Study Finds
A recent cross-sectional study found that dobutamine stress echocardiography (DSE) provides high specificity (97.4%) for ruling out cardiac-related mortality in liver transplant patients. However, its 0% sensitivity limits its utility as a standalone screening tool, as it fails to identify patients at risk for early perioperative cardiac events.
The findings are published in June 2025 in the Indian Heart Journal.
The Challenge of Pre-Transplant Cardiac Evaluation
Cardiovascular complications are a leading cause of morbidity and mortality for patients undergoing liver transplantation, particularly within the first month post-procedure. The prevalence of coronary artery disease (CAD) in the end-stage liver disease population ranges from 18% to 27%, making thorough preoperative cardiac risk stratification essential to minimize perioperative risk. However, traditional invasive tests like coronary angiography (CAG) are often deferred in patients with decompensated cirrhosis due to risks of bleeding, infectious complications, and renal failure. Consequently, noninvasive alternatives like dobutamine stress echocardiography are widely used, yet their diagnostic accuracy and prognostic value in this specific population remain a subject of evolving debate.
Study Overview
The cross-sectional prospective observational study was conducted at a tertiary cardiac center in South India between June 2020 and November 2021. The analysis included 94 patients aged 40 years or older with two or more cardiovascular risk factors—such as diabetes, hypertension, and smoking—who were undergoing evaluation prior to liver transplantation. The study categorized participants into ischemic, non-ischemic, or indeterminate groups based on their responses to dobutamine and monitored 30-day outcomes, including mortality, major adverse cardiac events (MACE), intensive care unit (ICU) stay, and inotrope requirements.
The key findings from the study include:
• Among the 94 patients, 88.3% were classified as non-ischemic, 9.6% as indeterminate, and only 2.1% as ischemic.
• Both patients with ischemic results underwent coronary angiography, which revealed non-significant coronary disease.
• The 30-day mortality rate was 10.6% (10 patients), though only one death was attributed to a cardiac cause—specifically acute pulmonary embolism.
• DSE failed to predict MACE; the only two recorded events—acute coronary syndrome (ACS) and heart failure (HF)—occurred in patients who previously had negative DSE results.
• The negative predictive value for mortality was 89.2%, but the sensitivity for predicting cardiac events was 0%.
Clinical Relevance and Targeted Prevention
For transplant teams, this study confirms that while a negative DSE provides high specificity (97.4%), it lacks the sensitivity required to identify all patients at risk for early post-transplant cardiac complications. The occurrence of major adverse cardiac events in DSE-negative patients—diagnosed via symptoms, electrocardiogram changes, and elevated N-terminal pro-brain natriuretic peptide (NT-pro BNP) or troponins—questions the role of DSE as a standalone test. Clinicians should consider a broader cardiovascular risk profile, including the management of diabetes and hypertension, rather than relying solely on stress imaging. Where strong clinical suspicion of coronary artery disease remains despite a negative DSE; alternative diagnostic tests or invasive coronary angiography should be considered to ensure patient safety.
Reference
Neusha D, Agarwala MK, Varma MC, Firdouse S, Demel R. Dobutamine stress echocardiography in end-stage liver disease: Insights from pre-transplant cardiac assessment – A cross-sectional prospective study from a tertiary cardiac centre in South India. Indian Heart Journal. 2025;77(2):354-358.
