Skip to main content
The Egyptian Journal of Internal Medicine
Download PDF
  • Original article
  • Open access
  • Published:

Predictors of myocardial injury in patients with cirrhosis presenting with upper gastrointestinal bleeding

The Egyptian Journal of Internal Medicine volume 31, pages 508–513 (2019)Cite this article

Abstract

Background

Myocardial injury in conditions other than coronary artery disease (CAD), known as type 2 myocardial infarction, is mostly related to mismatch between myocardial oxygen supply and demand. Cirrhotic patients with acute upper gastrointestinal bleeding (UGIB) are usually hemodynamically unstable. Hypovolemia, hypotension, and decreased oxygen-carrying capacity as consequences of UGIB may precipitate subclinical heart failure and myocardial injury.

Aim of work

Assessment of the prevalence and potential risk factors of myocardial injury in patients with liver cirrhosis with acute UGIB.

Patients and methods

The study was conducted on 132 patients diagnosed with liver cirrhosis presenting by UGIT bleeding at Mansoura University Hospitals during one year. Patients were divided into 2 groups: group 1 (76 patients) with myocardial injury or ischemic heart disease and group 2 (60 patients) without.

Results

The incidence of myocardial injury in this study (elevated troponin levels above cutoff value and/or ECG changes) was 55% of patients. Troponin I was positive in 25% of patients. ECG ischemic changes were found in 36.3% of patients in the form of ST-segment deviation or T-wave inversion. On univariate analysis, predictors of myocardial injury in patients with UGIB included MELD score and variceal source of GI bleeding. On multivariate analysis variceal source of GI bleeding is an independent predictor of myocardial injury. Variceal bleeding was found in 95 % of the ischemic group versus 63% in the other group.

Conclusion

More than half of the study patients presented with UGIB have suffered from unnoticed subclinical myocardial injury. Variceal source of GI bleeding was found to be an independent predictor of myocardial injury.

References

  1. Hopper AD, Sanders DS. Upper GI bleeding requires prompt investigation. Practitioner 2011; 255:15–19.

    PubMed  Google Scholar 

  2. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922–938.

    Article  CAS  Google Scholar 

  3. Sandoval Y, Smith SW, Schulz KM, Murakami MM, Love SA, Nicholson J, et al. Diagnosis of type 1 and type 2 myocardial infarction using a high-sensitivity cardiac troponin I assay with sex-specific 99th percentiles based on the third universal definition of myocardial infarction classification system. Clin Chem 2015; 61:657–663.

    Article  CAS  Google Scholar 

  4. Bhatti N, Amoateng-Adjepong Y, Qamar A, Manthous CA. Myocardial infarction in critically III patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes. Chest 1998; 114:1137–1142.

    Article  CAS  Google Scholar 

  5. Lee MY, Chu CS, Lee KT, Lee HC, Su HM, Cheng KH, et al. Terlipressin-related acute myocardial infarction: a case report and literature review. Kaohsiung J Med Sci 2004; 20:604–608.

    Article  Google Scholar 

  6. Emenike E, Srivastava S, Amoateng-Adjepong Y, Al-Kharrat T, Zarich S, Manthous CA. Myocardial infarction complicating gastrointestinal hemorrhage. Mayo Clin Proc 1999; 74:235–241.

    Article  CAS  Google Scholar 

  7. Pugh R, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973; 60:646–649.

    Article  CAS  Google Scholar 

  8. Freeman RB, Wiesner RH, Harper A, McDiarmid SV, Lake J, Edwards E, et al. The new liver allocation system: moving toward evidence-based transplantation policy. Liver Transpl 2002; 8:851–858.

    Article  Google Scholar 

  9. Rockall TA, Devlin HB, Logan RF, Northfield TC. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet 1996; 347:1138–1140.

    Article  CAS  Google Scholar 

  10. Kırıs T, Avcı E, Çelik A. Combined value of left ventricular ejection fraction and the model for end-stage liver disease (MELD) score for predicting mortality in patients with acute coronary syndrome who were undergoing percutaneous coronary intervention. BMC Cardiovasc Disord 2018; 18:44.

    Article  Google Scholar 

  11. Sorbi D, Gostout CJ, Peura D, Johnson D, Lanza F, Foutch PG, et al. An assessment of the management of acute bleeding varices: a multicenter prospective member-based study. Am J Gastroenterol 2003; 98:2424–2434.

    Article  Google Scholar 

  12. Bellotto F, Fagiuoli S, Pavei A, Gregory SA, Cati A, Silverj E, et al. Anemia and ischemia: myocardial injury in patients with gastrointestinal bleeding. Am J Med 2005; 118:548–551.

    Article  Google Scholar 

  13. Wu I-C., Yu F-J., Chou J-J., Lin T-J., Chen H-W., Lee C-S., et al. Predictive risk factors for upper gastrointestinal bleeding with simultaneous myocardial injury. Kaohsiung J Med Sci 2007; 23:8–16.

    Article  Google Scholar 

  14. Iser DM, Thompson AJ, Sia KK, Yeomans ND, Chen RY. Prospective study of cardiac troponin I release in patients with upper gastrointestinal bleeding. J Gastroenterol Hepatol 2008; 23:938–942.

    Article  Google Scholar 

  15. Hamid EF, Emara MH, El-Hawari SA, Ateya AA, Sherbeni AS. Upper gastrointestinal bleeding associated with myocardial injury in Egyptian patients: frequency and risk factors. J Gastroenterol Hepatol Res 2013; 2:419–422.

    Google Scholar 

  16. Prendergast HM, Sloan EP, Cumpston K, Schlichting AB. Myocardial infarction and cardiac complications in emergency department patients admitted to the intensive care unit with gastrointestinal hemorrhage. J Emerg Med 2005; 28:19–25.

    Article  Google Scholar 

  17. Wong CC, Ng AC, Lau JK, Chow V, Chen V, Ng AC, et al. High mortality in patients presenting with acute pulmonary embolism and elevated INR not on anticoagulant therapy. Thromb Haemost 2016; 115:1191–1199.

    Article  Google Scholar 

  18. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, Ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31:864–871.

    Article  CAS  Google Scholar 

  19. Wiesner R, Edwards E, Freeman R, Harper A, Kim R, Kamath P, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003; 124:91–96.

    Article  Google Scholar 

  20. Kim MS, Kato TS, Farr M, Wu C, Givens RC, Collado E, et al. Hepatic dysfunction in ambulatory patients with heart failure: application of the MELD scoring system for outcome prediction. J Am Coll Cardiol 2013; 61:2253–2261.

    Article  Google Scholar 

  21. Wernly B, Lichtenauer M, Franz M, Kabisch B, Muessig J, Masyuk M, et al. Model for End-stage Liver Disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance. PloS One 2017; 12:e0170987.

    Article  Google Scholar 

  22. Corey KE, Kartoun U, Zheng H, Chung RT, Shaw SY. Using an electronic medical records database to identify non-traditional cardiovascular risk factors in nonalcoholic fatty liver disease. Am J Gastroenterol 2016; 111:671.

    Article  Google Scholar 

  23. Simon TG, Kartoun U, Zheng H, Chan AT, Chung RT, Shaw S, Corey KE. Model for end-stage liver disease Na score predicts incident major cardiovascular events in patients with nonalcoholic fatty liver disease. Hepatology Commun 2017; 1:429–438.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Internal Medicine, Critical Care, Mansoura University, Mansoura, Egypt

    Rehab Shaheen & Tarek Gouda

  2. Department of Internal Medicine, Hepatology and Gastroenterology, Mansoura University, Mansoura, Egypt

    Monir Bahgat & Hazem Hakim El-Beltagy El-Menshawy

  3. Department of Clinical Pathology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Tarek Selim

  4. Department of Anaesthesia and ICU, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

    Elsayed Awad

Authors
  1. Rehab Shaheen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tarek Gouda
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Monir Bahgat
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tarek Selim
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hazem Hakim El-Beltagy El-Menshawy
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Elsayed Awad
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hazem Hakim El-Beltagy El-Menshawy.

Additional information

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shaheen, R., Gouda, T., Bahgat, M. et al. Predictors of myocardial injury in patients with cirrhosis presenting with upper gastrointestinal bleeding. Egypt J Intern Med 31, 508–513 (2019). https://doi.org/10.4103/ejim.ejim_71_18

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/ejim.ejim_71_18

Keywords