Diagnostic accuracy and cost-effectiveness of the CAR-OLT score in predicting cardiac risk for liver transplantation.

Background: The CAR-OLT score predicts major adverse cardiovascular events 1 year after liver transplant (LT).

Aim: To test the hypothesis that the CAR-OLT score may help avoid cardiac stress tests in LT candidates.

Methods: This retrospective single-center cohort study included all adult patients undergoing elective evaluation for first cadaveric donor orthotopic LT for liver cirrhosis with or without hepatocellular carcinoma at Fondazione Policlinico Universitario Agostino Gemelli Istituto di Ricerca e Cura a Carattere Scientifico in Rome, Italy. Cardiac contraindications for LT listing were defined after a center-specific cardiac workup, which included cardiac stress tests for most patients. The diagnostic accuracy of the CAR-OLT score was evaluated using the area under the receiver operating characteristic (AUROC) method.

Results: A total of 342 LT candidates were evaluated between 2015 and 2019, with a moderate cardiovascular risk profile (37% diabetes, 34% hypertension, 22% obesity). Of these, 80 (23%) candidates underwent coronary angiography. Twenty-one (6%) candidates were given cardiac contraindications to LT listing, 48% of which were due to coronary artery disease. The CAR-OLT score predicted cardiac contraindications to LT listing with an AUROC of 0.81. The optimal cut-off for sensitivity was a CAR-OLT score ≤ 23, which showed a 99% negative predictive value for cardiac contraindications to LT listing. A total of 84 (25%) LT candidates with a CAR-OLT score ≤ 23 underwent 87 non-invasive cardiac tests and 13 coronary angiographies pre-listing, with estimated costs of approximately 48000€. The estimated savings per patient was €574.70 for the Italian National Health System.

Conclusion: A CAR-OLT score ≤ 23 can identify LT candidates who can be safely listed without the need for cardiac stress tests, providing time and cost savings. These findings require external validation.