Detection and treatment of coronary artery disease in liver transplant candidates

Patients with end-stage liver disease and coronary artery disease (CAD) bei ng considered for orthotopic liver transplantation (OLT) present a difficul t dilemma. The availability of multiple screening tests and newer treatment options for CAD prompted this review. Recent data suggest that the prevale nce of CAD in patients with cirrhosis is much greater than previously belie ved and likely mirrors or exceeds the prevalence rate in the healthy popula tion. The morbidity and mortality of patients with CAD who undergo OLT with out 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 be fore OLT. Those with advanced CAD not amenable to interventional therapy or with poor cardiac function are not candidates for OLT. Dobutamine stress e chocardiogram appears to be an excellent means of screening patients with i ntermediate 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, les s likely, surgical intervention pre-OLT to correct obstructive coronary les ions. Prospective studies regarding optimal screening strategies for the pr esence of CAD and the indications, timing, and outcomes of interventional t herapy in patients with advanced cirrhosis are lacking and much needed.