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As a proxy for liver congestion, liver stiffness measured with ultrasound elastography has important prognostic value among patients with heart failure, a Japanese study suggested.

Patients in the highest tertile of liver stiffness were at (HR 3.57, 95% CI 1.93-6.83) over follow-up of more than 6 months, Tomohito Ohtani, MD, PhD, of Osaka University Graduate School of Medicine, and colleagues reported in their study published online in JACC: Cardiovascular Imaging.

For a model predicting 90-day cardiac events, a 10.1 kPa threshold for liver stiffness had sensitivity and specificity of 0.73 and 0.90, respectively, and a C-statistic of 0.823 (95% CI 0.682-0.964). Adding liver stiffness to a model consisting of age, gender, eGFR, and brain natriuretic peptide levels raised the C-statistic from 0.704 to 0.844 (P=0.006).

"Taken together, these results suggest that the assessment of liver congestion at discharge may aid in the management of heart failure patients," Ohtani's group concluded, saying it could "be used as a reliable indicator of subclinical residual liver congestion, which reflects the severity of heart failure, and of adverse cardiac events, even in patients with optimized heart failure treatment and without visible edema or elevated liver function test."

The Fibroscan transient elastography device provided liver stiffness readings for 171 hospitalized heart failure patients at Osaka University Hospital. Excluded were those with invalid liver stiffness measures (8% of those screened in the hands of a single experienced examiner), liver disease, or a history of alcohol abuse.

Median liver stiffness was 5.6 kPa, which translates to a right-sided filling pressure of 5.7 mm Hg. A liver stiffness reading over 6.9 kPa (corresponding to an estimated right-sided filling pressure of over 7.1 mm Hg) placed patients in the highest tertile.

The stiffest livers were more likely to be observed in patients with moderate-to-severe heart failure, larger inferior vena cava diameter, higher serum direct bilirubin, and more concentrated brain natriuretic peptide levels. Multivariable adjustment still yielded a significant relationship between liver stiffness and heart failure outcomes.

Ohtani and colleagues acknowledged that no confirmatory liver biopsies were done, however, and that their sample size was quite small.

Even so, an said that "one of the main strengths of liver stiffness is summarized in the methodology of this study: the authors performed only one analysis of liver stiffness per patient, at the discharge, and were able to glean numerous clinically significant results. This reminds us of the simplicity of use of this imaging tool: it is done at the patient's bed, in a short time, and can be carried out by any doctor or specialist nurse practitioner."

"The higher the liver stiffness, the greater the risk of the patient to die. Stone liver, heart in danger, is in a way, the message of this work," according to editorialists Mathieu Pernot, PhD, and Olivier Villemain, MD, both of Institut Langevin in Paris.

"But probably future clinical studies will tell us whether decreasing liver stiffness can improve the prognosis of heart failure patients," they added. "And in this case, we will have new and valuable arguments for implementing therapeutic strategies to reduce hepatic congestion monitored by elastography, which will change our clinical practice. Thanks to the liver, we could have the means to better understand the right heart."