Liver cirrhosis was linked to an increased risk of stroke in a large retrospective study, and the association was independent of established cardiovascular risk factors, research has found.
In the study of almost 1.3 million people in Germany, a multivariate analysis showed a 21% higher risk of a cardiovascular event — stroke or myocardial infarction (MI) — in people with or without cirrhosis (7.7% versus 5.9%; HR 1.209, 95% CI 1.105-1.322), according to Benjamin Maasoumy, MD, of Hanover Medical School in Germany, who presented the results at the European Association for the Study of the Liver Meet.
But looking at the two components individually revealed a 37% higher risk of stroke in the cirrhosis group, but no higher risk of MI:
- Stroke: 5.1% versus 3.5% (HR 1.373, 95% CI 1.230-1.532)
- MI: 2.8% vs 2.6% (HR 0.972, 95% CI 0.838-1.127)
“The results are important, but they should be interpreted with caution,” said Omar Massoud, MD, PhD, of the Cleveland Clinic in Ohio. MedPage Today.
“It is possible that the increase in strokes in the cirrhosis group is at least partially related to the fact that the patients are older and male,” he noted. “Even though the investigators adjusted for some of these confounders, it remains unclear to what extent the increase in strokes is actually related to cirrhosis.”
Maasoumy noted that cirrhosis of the liver is associated with systemic inflammation and endothelial dysfunction, as well as disruption of hemostasis, which can lead to an increased risk of bleeding. But whether cirrhosis and adverse cardiovascular events are linked remains a matter of controversy.
“The question of why there is an increased incidence of stroke in people with cirrhosis remains to be explained,” said Andrew Talal, MD, of the University at Buffalo in New York. MedPage today.
“It’s also interesting to note that myocardial infarctions were not associated with cirrhosis,” said Talal, who was not involved in the study. “This may imply that inflammation may not be the causal cause originally assumed by investigators.”
For their population-based study, the researchers retrospectively looked at the insurance data of 1,290,057 people in northern Germany from 2013 to 2019. Of these, 6,517 had cirrhosis. Patients had to be permanently insured and were excluded if they had a cardiovascular event in the years preceding the study period. ICD-10 codes have been used to identify people with cirrhosis of the liver as well as risk factors for cardiovascular events.
Multivariate analysis adjusted for sex, age and some cardiovascular risk factors such as alcohol abuse, atherosclerosis, coronary heart disease, chronic renal failure, heart failure, hypertension , smoking, obesity, diabetes and dyslipidemia.
Advanced stage cirrhosis – evidenced by portal hypertension, esophageal varices or hepatic ascites/encephalopathy – was not linked to an increased risk of stroke or myocardial infarction, the researchers found. .
People with cirrhosis tended to be older than those without (mean 63 versus 56), had higher rates of hypertension (60% versus 44%) and diabetes (37% versus 16 %), and were more likely to be male (60% vs 45%) and alcohol abuser (40% vs 2%).
“Patients with cirrhosis may have coagulopathy, coronary artery disease, as well as type II diabetes and dyslipidemia, all of which are associated with the development of stroke. We are monitoring these patients closely,” said Arjmand Mufti, MD, of the University of Texas Southwestern Medical Center in Dallas, who was not involved in this study.
Mufti noted that it would have been useful to see a breakdown by ischemic versus hemorrhagic stroke, and whether the risk varied by etiology of cirrhosis.
Because the study used ICD codes, the stroke mechanism was unknown, Maasoumy said.
Maasoumy disclosed no conflict of interest.