Deterioration of subclinical atherosclerosis

markers during and after pegylated interferon

and ribavirin treatment for chronic hepatitis C

Alexandra Alexopoulou1, George Georgiopoulos2, Sofia

Pouriki1, Ilianna Mani1, Larisa Vasilieva1, Angeliki Laina2,

Dimitrios Zampetas1, Kimon Stamatelopoulos1, Spyros P

Dourakis1

12nd Department of Internal Medicine and Research Laboratory, Medical

School, National and Kapodistrian University of Athens, Hippokration

Hospital, Athens, Greece

2Vascular Laboratory, Department of Clinical Therapeutics, National and

Kapodistrian University of Athens, Alexandra University Hospital, 80 V.

Sofias Str, 11528 Athens, Greece

Conflict of interest

No conflict of interest to declare

Introduction

Interferon↑ adhesion of leukocytes to the

endothelium

↑ chemotaxis of platelets

Vascular damage : endothelial injury, micro-

infractions

Karbasi-Afshar R et al, Iranian journal of medical sciences. 2014;39(3):238-46.

Introduction

Myocardial infraction

Interferon

Chronic hepatitis C

Arrythmias

Cardiomyopathy Pulmonary hypertension

Karbasi-Afshar R et al, Iranian journal of medical sciences 2014, 39(3):238-46.

Salman H et al, Cancer 1999, 85(6):1375-9.

Evaluation of possible changes in vascular

markers of subclinical atherosclerosis during

and after PR treatment for CHC.

Aim

Methods

24 consecutive patients with CHC

• non smokers

• without diabetes or arterial hypertension

• 58.3%♂

• Mean age 43.1 (13.3)

24 healthy controls

Evaluation of

vascular markers in 3

visits

Before treatment

(T1)End of treatment

(T2)24 weeks post treatment

(T3)

Peg INF

Ribavirin

Liver disease

58.3%

14

37.5%

9

4.2%

1

25%

cirrhotics

Genotype

Result of treatment

83.3%

20

16.7%

4

Methods

1. Anthropometric measurements:

- Height

- Weight

- Body Mass Index

- Waist and hip circumference

2. Vascular tests :

- Flow-mediated, endothelium-dependent vasodilation – FMD

- Carotid-femoral pulse wave velocity (PWV)

- Pulse wave analysis (PWA)

- Peripheral and central systolic (SBP) and diastolic blood pressure

(DBP)

- Intima-media thickness (IMT) of the carotid artery

For each patient data that were collected, include :

Vascular tests were conducted in a fixed order by the

same operator who was blinded to the medical history

of the participants

DT

PWV = D/T

Measurement of pulse transit time and the distance travelled between the

common carotid artery and the common femoral artery (Complior, Artech

Medical, Pantin, France)

Carotid-femoral pulse wave velocity (PWV)(m/s)

Pulse wave analysis (PWA) at radial artery

Central systolic blood pressure (c_sbp)

Central diastolic blood pressure (c_dbp)

Αugmentation Ιndex, ΑΙx

P1

P2

Augmentation index =

(P2 – P1)/Pulse pressure x 100

Change

Between the

First and

second

Inflection point

Pre

ssu

re (

mm

Hg

)Time (milliseconds)

Pu

lse

pre

ssu

re

Estimation of aortic pressure waveforms and reflected waves

(SphygmoCor System (AtCor Medical Pty Ltd, Sydney, Australia)

Flow-mediated, endothelium-dependent vasodilation – FMD

A high-resolution ultrasound machine is used to estimate

increase in arterial blood flow as a result of reactive

hyperemia.(Vivid 7 Pro, General Electric, USA)

Intima-media thickness (IMT) of the carotid artery

Measurement of intima-media thickness and estimation of atherosclerosis

using B-MODE Ultrasound (14 MHZ Multi-frequency Linear Array Probe, Vivid 7

Pro, General Electric)

Parameters expressed as

Mean, (SD) or Median (IQR)Controls (n=24) HCV (n=24) p-value

Age (years) 47.3 (7.51) 43.1(13.3) 0.184

Gender, male n (%) 14 (58.3) 14 (58.3) 1.000

BMI (kg/m2) 28.5 (3.47) 26.2 (4.62) 0.129

Hyperlipidemia, n(%) 12 (50) 0 (0) <0.001

Waist, (cm) 98 (87-104) 96 (84-104) 0.545

Cirrhosis, n(%) - 6 (25%) NA

Sustained virological response,

n(%)

- 20 (83.3) NA

Genotype 1, n(%) - 14 (58.3%) NA

Genotype 3, n(%) - 9 (37.5%) NA

ALT (IU/L) 19.5 (11-30) 70 (52-124) <0.0001

SBP (mmHg) 120.3 (16.8) 122.3 (17.3) 0.693

DBP (mmHg) 76.3 (10.7) 74.5 (10.6) 0.572

Aortic SBP (mmHg) 112 (17.7) 112 (17.8) 1.00

Aortic DBP (mmHg) 77.9 (11.1) 75.6 (10.7) 0.503

Augmentation index at 75 bpm (%) 21.5 (16-29) 18.5 (11-27) 0.261

PWV (m/s) 9.05 (7.8-9.95) 7.8 (6.5-8.85) 0.075

FMD(%) 2.38 (0.781-4.76) 2.63 (2.09-6.07) 0.286

Combined IMT (mm) 0.081 (0.066-0.522) 0.068 (0.060-0.080) 0.055

Common carotid IMT (mm) 0.072 (0.055-0.439) 0.065 (0.057-0.075) 0.292

Carotid bifurcation IMT (mm) 0.099 (0.069-0.527) 0.073 (0.055-0.096) 0.028

Internal carotid IMT (mm) 0.077 (0.060-0.505) 0.065 (0.054.-0.087) 0.105

Baseline descriptive characteristics of the study population as allocated in

two groups of interest

T1 T2 T3Interaction

T1 vs T2

Interaction

T1 vs T3

mean±SD or

median(IQR)

mean±SD or

median(IQR)

mean±SD or

median(IQR)

Coefficient

(95%CIs)p value

Coefficient

(95%CIs)p value

SBP

CHC 122.3±17.3 126.7±16.5 123.9±14.5 0.784

(-11.141 to

12.7)

0.897

5.25

(-4.415 to

14.9)

0.287Controls 120.3±16.8 110.3±16.3 119.8±14.7

Aortic SBP

CHC 122.3 ± 17.3 116.3±15.5 114.8±14.3 0.699

(-10.192 to

11.6)

0.900

6.42

(-2.719 to

15.6)

0.169Controls 112± 17.7 103.3±17.8 112±13.9

Longitudinal changes in hemodynamic parameters of interest in our study

population across the pre-specified time points of assessment

Augmentation index

CHC 18.5 (11 to 27) 18 (14.5 to 26) 22.5 (14 to 29) 2.23

(-2.815 to

7.28)

0.3863.67

0.130 to 7.22)0.042

Controls21.5

(16 to 29)27 (17 to 33)

25.5

(22.5 to 31.5)

Pulse Wave Velocity

CHC7.8

(6.55 to 8.85)7.28

(6.78 to 7.9)

7.75

(7.3 to 8.9)0.036

(-0.792 to

0.864)

0.932

0.645

(0.037 to

1.25)

0.037

Controls9.05

(7.8 to 9.95)8.85

(7.65 to 9.55)

8.75

(7.75 to 9.2)

Flow Mediated Dilatation

CHC2.63

(2.09 to 6.07)

4.95

(3.92 to 7.11)

3.78

(1.26 to 7.49)-72%

(-92% to -2%)0.047

46.6%

(-79% to

601%)0.696

Controls2.38

(0.781 to 4.76)

3.13

(0.763 to 4.88)

4.88

(2.19 to 5.66)

Time to the beginning of the reflected wave

CHC149.5

(140 to 156)

145

(141 to 158)

144

(140 to 154) -2%

(-7% to 2%)0.351

-3%

(-6% to 0.3%) 0.071

Controls144

(130 to 148.5)

135

(126 to 151)

139.5

(132.5 to 144.5)

Longitudinal changes in vascular parameters of interest in our study population

across the pre-specified time points of assessment

T1 T2 T3Interaction

T1 vs T2

Interaction

T1 vs T3

mean±SD or

median(IQR)

mean±SD or

median(IQR)

mean±SD or

median(IQR)

Coefficient

(95%CIs)p value

Coefficient

(95%CIs)p value

Longitudinal changes in pulse wave velocity per group of

interest (CHC patients or healthy controls) across the follow

up

9.5

9

8.5

8

P = 0.932 P = 0.037

T1 T2 T3

7.5

7

Pu

lse w

ave v

elo

cit

y (

m/s

)

Controls CHC patients

20

15

P = 0.386 P = 0.042

T1 T2 T3

25

Controls CHC patients

Au

gm

en

tati

on

in

de

x (

%)

Longitudinal changes in augmentation index per group of

interest (CHC patients or healthy controls) across the follow

up

Study limitations

Small sample size

Short follow up period

Circulating markers of endothelial function were not

measured in the study and endothelial dysfunction was

evaluated solely by FMD.

Peg INF Ribavirin

+

Conclusions

Markers of subclinical

atherosclerosis deteriorate in

patients with CHC during PR. This

deterioration continues at least 6

months after stopping treatment.

Longitudinal changes in aortic diastolic blood pressure

(DBP) per group of interest (CHC patients or healthy

controls) across the follow up

Ao

rtic

dia

sto

lic b

loo

d p

lessu

re (

mm

Hg

)

P = 0.214 P = 0.003

85

80

75

70

65

T1 T2 T3

Controls HCV patients

Methods

Before visits, abstain of :

for 24 hours

for 12 hours

Vascular measurements were performed in every visit, as

described below

Blood pressure was recorded in each subject twice (1 minute

apart) by oscillometry using the automated Omron 705IT device

(Omron) after resting in the sitting position for 5 minutes

0.251 (0.228-0.388) 0.405 (0.238-0.472)

P = 0.017

Comparison of median max diameter of branchial artery after

reactive hyperemia before treatment and 24 weeks post

treatment

Before treatment 24 weeks post treatment

ma

x d

iam

ete

r o

f b

ran

ch

ial a

rte

ry a

fte

r

rea

cti

ve

hyp

ere

mia

, m

m

116.00 (101.00-124.00)112.00 (96.25-120.25)

P = 0.034

Comparison of median c_ sbp before treatment and 24 weeks

post treatment

Ce

ntr

al s

ys

tolic

blo

od

pre

ss

ure

(m

mH

g)

Before treatment 24 weeks post treatment

26.50 (18.00-36.00) 24.00 (15.75-31.25)

P = 0.044

Au

gm

en

tati

on

in

de

x (

Alx

, %

)Comparison of median Αugmentation index (AIx) before

treatment and 24 weeks post treatment

Before treatment 24 weeks post treatment

7.55 (7.07-9.20) 7.50 (6.55-8.47)

P = 0.028

Comparison of median PWVf before treatment and 24 weeks

post treatment

24 weeks post treatmentBefore treatment

7.75 (7.25-9.05) (7.27 (6.79-7.95)

P = 0.080

Comparison of median PWVf at the end of treatment and 24

weeks post treatmentP

uls

e W

ave

Ve

loc

ity F

em

ora

l (P

WV

f, m

/s)

End of treatment 24 weeks post treatment

Wa

ist

cir

cu

mfe

ren

ce

, c

mComparison of median waist circumference in HCV patients

before treatment and at the end of treatment

104.0 (92.5-107.0) 107 (98.0-112.0)

P = 0.023

Before treatment End of treatment

Beginning of therapy till 23 weeks post therapy

Parameter Adjusted Alteration (95% CI) P

Alx Alteration in systolic blood

pressure (F0,F3,F4), BMI

(F0,F3,F4), Age (F1), Gender

↑2.25% (0.972,3.53

)

0.002

24 weeks post treatment compared with end of treatment

PWV Alteration in systolic blood

pressure (F0,F3,F4), BMI

(F0,F3,F4), Age (F1), Gender,

cirrhosis

0.6m/s(0.122,1.06)

0.018

LINEAR MIXED MODELS – SVR patients (n=20)

specified time points of assessment

T1 T2 T3 Interaction T1 vs T2 Interaction T1 vs T3

mean±SD or

median(IQR)

mean±SD or

median(IQR)

mean±SD or

median(IQR)

Coefficient

(95%CIs)p value

Coefficient

(95%CIs)p value

SBP

CHC 122.3±17.3 126.7±16.5 123.9±14.5 0.784

(-11.141 to

12.7)

0.897

5.25

(-4.415 to

14.9)

0.287Controls 120.3±16.8 110.3±16.3 119.8±14.7

DBP

CHC 74.5 ± 10.6 75.8±8.47 73.5±10.2 3.84

(-2.812 to

10.5)

0.2587.67

(2.03 to 13.3)0.008

Controls 76.3±10.7 69.1±7.82 72.1 ±8.54

Aortic SBP

CHC 122.3 ± 17.3 116.3±15.5 114.8±14.3 0.699

(-10.192 to

11.6)

0.900

6.42

(-2.719 to

15.6)

0.169Controls 112± 17.7 103.3±17.8 112±13.9

Aortic DBP

CHC 75.6 ± 10.7 77±8.31 75.5±10.2 4.20

(-2.434 to

10.8)

0.2148.82

(2.93 to 14.7)0.003

Controls 77.9± 11.1 70.4±8.82 73.8±9.40

*Augmentation index

CHC 18.5 (11 to 27) 18 (14.5 to 26) 22.5 (14 to 29) 2.23

(-2.815 to

7.28)

0.3863.67

0.130 to 7.22)0.042

Controls21.5

(16 to 29)27 (17 to 33)

25.5

(22.5 to 31.5)

*Pulse Wave Velocity

CHC7.8

(6.55 to 8.85)7.28

(6.78 to 7.9)

7.75

(7.3 to 8.9)0.036

(-0.792 to

0.864)

0.9320.645

(0.037 to 1.25)0.037

Controls9.05

(7.8 to 9.95)8.85

(7.65 to 9.55)

8.75

(7.75 to 9.2)

*Flow Mediated Dilatation

CHC2.63

(2.09 to 6.07)

4.95

(3.92 to 7.11)

3.78

(1.26 to 7.49) -72%

(-92% to -2%)0.047

46.6%

(-79% to

601%)0.696

Controls2.38

(0.781 to 4.76)

3.13

(0.763 to 4.88)

4.88

(2.19 to 5.66)

Beginning of therapy till 23 weeks post therapy

Parameter Adjusted Alteration (95% CI) P

Alx Alteration in systolic blood pressure

(F0,F3,F4), BMI (F0,F3,F4), Age (F1),

Sex

↑1.52% (0.45, 2.55) 0.006

Alx Alteration in systolic blood pressure,

(F0,F3,F4), BMI (F0,F3,F4), Age (F1),

Sex, cirrhosis, genotype of HCV

↑4.2% (1.42,6.99) 0.005

Max diameter of

brachial artery

after reactive

hyperemia

Alteration in systolic blood pressure

(F0,F3,F4), BMI (F0,F3,F4), Age (F1),

Gender, cirrhosis, genotype of HCV ↓-0.05mm (-0.084, -0.017) 0.005

LINEAR MIXED MODELS(n=26)

25.78 (23.01-29.66) 25.15 (22.88-29.24)

P = 0.022

Comparison of median BMI in HCV patients before treatment

and at the end of treatmentB

od

y M

as

s In

de

x, B

MI k

g/

m2

Before treatment End of treatment

ΣΥΓΚΡΙΣΗ ΤΙΜΩΝ AIx ΠΡΙΝ ΤΗΝ ΕΝΑΡΞΗ ΤΗΣ ΘΕΡΑΠΕΙΑΣ

ΚΑΙ 24 ΕΒΔΟΜΑΔΕΣ ΜΕΤΑ ΤΗΝ ΟΛΟΚΛΗΡΩΣΗ ΘΕΡΑΠΕΙΑΣ

ΓΟΝΟΤΥΠΟΣ 1

23.00 (14.25-33.00) 22.00 (11.00-29.00)

P = 0.022

Au

gm

en

tati

on

in

de

x (

Alx

, %

)

ΣΥΓΚΡΙΣΗ ΔΙΑΜΕΣΩΝ ΟΡΩΝ ΤΙΜΩΝ AIX ΠΡΙΝ ΤΗΝ ΕΝΑΡΞΗ

ΤΗΣ ΘΕΡΑΠΕΙΑΣ ΚΑΙ 24 ΕΒΔΟΜΑΔΕΣ ΜΕΤΑ ΤΗΝ

ΟΛΟΚΛΗΡΩΣΗ ΘΕΡΑΠΕΙΑΣ

ΓΟΝΟΤΥΠΟΣ 3

20.00 (13.50-26.50) 15.50 (10.25-23.50

P=0.050

Au

gm

en

tati

on

in

de

x (

Alx

, %

)

ΣΥΓΚΡΙΣΗ ΤΙΜΩΝ ΜΕΓΙΣΤΗΣ ΔΙΑΜΕΤΡΟΥ ΤΟΥ ΑΓΓΕΙΟΥ ΜΕΤΑ ΤΗΝ

ΑΝΤΙΔΡΑΣΤΙΚΗ ΥΠΕΡΑΙΜΙΑ ΠΡΙΝ ΤΗΝ ΕΝΑΡΞΗ ΤΗΣ ΘΕΡΑΠΕΙΑΣ ΚΑΙ 24

ΕΒΔΟΜΑΔΕΣ ΜΕΤΑ ΤΗΝ ΟΛΟΚΛΗΡΩΣΗ ΘΕΡΑΠΕΙΑΣ

ΓΟΝΟΤΥΠΟΣ 1

0.247 (0.231-0.390) 0.410 (0.382-0.472)

P = 0.051