Coronary artery disease in NASH-related cirrhosis
Authors: Abdurrahman Kadayifci, Nathan M. Bass
Journal: Journal of Hepatology (2009)

We thank Drs. Kalaitzakis and Björnsson [[1]Kalaitzakis E. Björnsson E. Coronary artery disease in liver cirrhosis: Does the aetiology of liver disease matter?.J Hepatol. 2009; 51: 962Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar] for their interest in our paper [[2]Kadayifci A. Tan V. Ursell P.C. Merriman R.B. Bass N.M. Clinical and pathologic risk factors for atherosclerosis in cirrhosis: a comparison between NASH-related cirrhosis and cirrhosis due to other aetiologies.J Hepatol. 2008; 49: 595-599Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar] and for providing their data that supports our observation of a high prevalence of coronary artery disease in patients with cirrhosis from non-alcoholic steatohepatitis (NASH) compared to those with cirrhosis of other aetiologies (COE). The authors point to the absence of patients with alcoholic liver disease (ALD) among patients with COE in our study [[2]Kadayifci A. Tan V. Ursell P.C. Merriman R.B. Bass N.M. Clinical and pathologic risk factors for atherosclerosis in cirrhosis: a comparison between NASH-related cirrhosis and cirrhosis due to other aetiologies.J Hepatol. 2008; 49: 595-599Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. Indeed, our study differed in its primary goal and selected population from their recent publication [[3]Kalaitzakis E, Rosengren A, Skommevik T, Björnsson E. Coronary artery disease in patients with liver cirrhosis. Dig Dis Sci 2009 Feb 26 [Epub ahead of print].Google Scholar] that demonstrated a high prevalence of coronary artery disease among patients with predominantly alcoholic cirrhosis. The primary objective of our study was to evaluate the relationship between NASH-related cirrhosis and coronary artery disease (CAD), compared with other aetiologies of cirrhosis, in a population that had undergone liver transplantation. The selection bias in our age and sex-matched COE group, comprised of only patients with viral hepatitis and cholestatic liver disease, reflects the leading causes of liver cirrhosis in patients undergoing liver transplantation at our center. “Pure” alcoholic cirrhosis is an unusual indication for liver transplantation at our center, although in a significant number of patients with hepatitis C, alcohol is considered a contributing factor to the development of cirrhosis. The data discussed in the letter by Kalaitzakis and Björnsson confirms a high prevalence of CAD in patients with NASH-related cirrhosis compared to cirrhosis secondary to other causes (excluding ALD) which supports our observations [[2]Kadayifci A. Tan V. Ursell P.C. Merriman R.B. Bass N.M. Clinical and pathologic risk factors for atherosclerosis in cirrhosis: a comparison between NASH-related cirrhosis and cirrhosis due to other aetiologies.J Hepatol. 2008; 49: 595-599Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. However, their finding of a high prevalence of CAD in ALD-cirrhosis is interesting and unexpected, given the results of previous autopsy studies [4Howell W.L. Manion W.C. The low incidence of myocardial infarction in patients with portal cirrhosis of the liver: a review of 639 cases of cirrhosis of the liver from 17,731 autopsies.Am Heart J. 1960; 60: 341-344Abstract Full Text PDF PubMed Scopus (70) Google Scholar, 5Vanecek R. Atherosclerosis and cirrhosis of the liver.Bull World Health Organ. 1976; 53: 567-570PubMed Google Scholar] and the protective effect of moderate alcohol consumption on atherosclerosis suggested by many other studies [6Kannel W.B. Ellison R.C. Alcohol and coronary heart disease: the evidence for a protective effect.Clin Chim Acta. 1996; 246: 59-76Crossref PubMed Scopus (157) Google Scholar, 7Suzuki K, Elkind MS, Boden-Albala B, Jin Z, Berry G, Di Tullio MR, et al. Moderate alcohol consumption is associated with better endothelial function: a cross sectional study. BMC Cardiovasc Disord 2009 Feb 20; doi:10.1186/1471-2261-9-8.Google Scholar]. In their study population [1Kalaitzakis E. Björnsson E. Coronary artery disease in liver cirrhosis: Does the aetiology of liver disease matter?.J Hepatol. 2009; 51: 962Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 3Kalaitzakis E, Rosengren A, Skommevik T, Björnsson E. Coronary artery disease in patients with liver cirrhosis. Dig Dis Sci 2009 Feb 26 [Epub ahead of print].Google Scholar] the incidence of important risk factors for CAD including age, smoking, male gender, hypertension and diabetes were higher in ALD-cirrhosis compared to their COE group. These findings not only point to the consistent importance of cardiovascular risk factors in determining the risk of CAD in a group (ALD) conventionally considered to be protected from CAD, but also raise the important question of the relative contribution of alcohol and metabolic factors in the pathogenesis of cirrhosis in their patients etiologically classified as ALD.