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Eur J Heart Fail. 2016 Jul;18(7):830-9. doi: 10.1002/ejhf.532. Epub 2016 May 12.

Abnormal liver function tests in acute heart failure: relationship with clinical characteristics and outcome in the PROTECT study.

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Department of Heart Diseases, Medical University, Wroclaw, Poland.
Department of Cardiology, Centre for Heart Diseases, Clinical Military Hospital, Wroclaw, Poland.
Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherland.
Merck Research Laboratories, Rahway, NJ, USA.
National Heart and Lung Institute, Imperial College London (Royal Brompton and Harefield Hospitals) Department of Cardiology, Castle Hill Hospital, University of Hull, UK.
Momentum Research Inc., Durham, NC, USA.
University of Iowa Carver College of Medicine Cardiovascular Research Center, Iowa City, IA, USA.
Duke Clinical Research Institute, Division of Cardiovascular Medicine, Duke University Medical Center, Durham, NC, USA.
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA.
Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.



Episodes of acute heart failure (AHF) unfavourably affect multiple organs, which may have an adverse impact on the outcomes. We investigated the prevalence and clinical consequences of abnormal liver function tests (LFTs) in AHF patients enrolled in the PROTECT study.


The LFTs comprised serial assessment of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and albumin at baseline and during follow-up (daily until discharge, on days 7 and 14). The prevalence of abnormal LFTs (above upper limit of normal for AST and ALT or below lower limit of normal for albumin) was: at baseline AST 20%, ALT 12%, albumin 40%; and at day 14: AST 15%, ALT 9%, albumin 26%. Abnormal LFTs at baseline were associated with a higher risk of in-hospital death with odds ratios [95% confidence interval (CI)] of 3.5 (1.7-7.3) for AST, 3.9 (1.8-8.4) for ALT, and 2.8 (1.3-5.9) for albumin (all P < 0.01). Abnormal baseline and discharge LFTs had an unfavourable impact on 180-day mortality with hazard ratios (95% CI) for baseline AST, ALT, and albumin of 1.3 (1.0-1.7), 1.1 (1.0-1.2), 1.4 (1.1-1.8), respectively, and 1.5 (1.1-2.0), 1.5 (1.0-2.2), and 1.6 (1.2-2.1), for discharge AST, ALT, albumin, respectively (all P < 0.05). Analysis of LFTs trajectories (calculated as changes in LFTs over time) revealed that increasing AST and ALT on day 3 as well as decreasing albumin on day 4 were independent prognosticators of 180-day outcome (all P < 0.05).


Abnormal LFTs are frequent in AHF at baseline and during hospital stay and predict worse outcomes. Whether this association is causal and what are the underlying mechanisms involved require further study.


Acute heart failure; Liver dysfunction; Liver function tests; Prognosis

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