Hepatitis C infection among patients with coronary artery disease

BYDr.Hesham Mohamed Salah El.Din

HCV

CAD

Introduction

Egypt has the largest epidemic of hepatitis C in the world. The hepatitis C virus (HCV) epidemic in Egypt is unique in the world and well documented in the international medical scientific literature .The percentage of Egyptians with HCV viraemia is 9.8%.(Imam et al., 2014)

This is greater than any other country in the world. The prevalence of HCV in Western countries is less than 2% (Ann et al,. 2009)

Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide, with >4.5 million deaths occurring in the developing world. ( Eisenberg et al., 2012)

People with chronic Hepatitis C infection are known to have an elevated risk for cardiovascular disease. Despite this understanding, the usual markers of cardiovascular disease may not necessarily apply to those with Hepatitis C. This is because the circulatory systems of people with Hepatitis C appear to contain less fat than the general population. (Chettaoui et al., 2012).

Recent studies support the role of inflammation in the pathogenesis of CAD. According to these studies ,a complex balance between pro-inflammatory and anti-inflammatory cytokines dictates the initiation, propagation ,and rupture of atherosclerotic lesions.

Some studies have shown that the levels of inflammatory markers (e.g., high sensitivity C-reactive protein, interleukin6, and tumor necrosis factor) are higher in HCV- infected subjects, compared with HCV-uninfected control subjects . Since inflammation and thrombosis are critical pathways in the genesis of CAD and since HCV infection is also associated with alterations in inflammatory markers , this might be the common pathway that increases CAD risk.(Adeel et al., 2009)

The aim of the work is to :-

evaluate the frequency of HCV infection among patient with coronary artery disease. And to assess the possible role of HCV infection as an independent risk factor for CAD and also its relation to disease severity.

SUBJECTS AND METHODS

The study included 212 patients admitted for coronary angiography in Cardiology Departement Zagazig University Hospitals with a clinical history suggestive of coronary artery disease .

Patients were diagnosed to have coronary artery disease if they had an angiographic documentes of coronary stenosis ≥50% in one or more coronary artery.

Exclusion Criteria

- decopansated cirrhosis,Hepatocellular carcinoma.

- Hepatitis B infection . - Hemochromatosis . - chronic inflammatory disorders,

immunological disorders,(as IBD,RA , Autoimmune hepatitis)

- previous treatment with antiviral therapy (Peg INF + Ribavirin) were excluded.

A) Full history and clinical examination

B) Routine investigations: 1-Complete blood picture. 2-HBsAg , HBcAb and HCV Ab.(by third generation assay)

3 -Fasting and post prandial plasma glucose level . 4 -Liver enzymes: serum alanine transferase and aspartate transferase .

5 -serum creatinine . 6 -Serum iron and ferritin 7 -Lipid profile: including:

a) Serum total cholesterol level. b) Serum triglycerides . c) HDL- cholesterol . d) LDL- cholesterol .  8- ANA, ESR, ASMA, AFP, RF.  9- Abdominal Ultrasonograhy . 

C) cardiac catheterization(coronary angiography ) to determine the following: 1-Number of vessels affected. 2-Type of lesions 3-Severity of lesion.according to SYNTAX Score and American Heart AssociationClassification (significant lesion is considered if there is ≥50 % stenosis).

212

111

Group A (With CAD)

42 (37.8%)

A1HCV +ve

69(62.2%)

A2HCV -ve

101Group B (NO CAD)

25(24.7%)

B1HCV +ve

76(75.3%)

A2HCV -ve

In a comparizon between group A &group B there were no significant difference

between the two groups as regard the Age, sex , BMI or the biochemical markers

However,the T. Cholesterol and Triglycrides were higher in group A than group B

In a comparizon between group A1 &group A2 there were no significant difference

between the two groups as regard the Age, sex , BMI or the biochemical markers

It is worth noting that, the T. Cholesterol and Triglycrides were lower in group A1 than group A2.

  HCV +VE (A1)N=42

HCV –VE (A2)N=69

Four vessel occlusion 6 (14.2%) 2 (2.8%)

Three vessel occlusion 21 (50%) 11 (15%)

Two vessel occlusion 10 (23.8%) 25 (36.2%)

One vessel occlusion 5 (11.9%) 31 (44%)

Disease severity of group A1 &A2

One vessele occlu-

sion; 31; 45%

Two vessele occlu-

sion; 25; 36%

Three vessele occlu-

sion; 11; 16%

Four vessele occlusion; 2; 3%

HCV -VE

One vessele occlusion; 5;

12%

Two vessele occlu-

sion; 10; 24%

Three vessele

occlusion; 21; 50%

Four ves-sele oc-

clusion; 6; 14%

HCV +VE

A1A2

According to the number of occluded coronary vessels with a significant lesion it is observed that 14.2% of patients with hepatitis C have occlusion in four vessels while only 2.8% of patients without hepatitis C have occlusion in

four vessels. And 50% of patients with hepatitis C have occlusion in three vessels while only 15% of patients without hepatitis C have occlusion in

three vessels

In a comparizon between group B1 &group B2 there were no significant difference

between the two groups as regard the Age, sex , BMI or the biochemical markers

It is worth noting that, the T. Cholesterol and Triglycrides were lower in group B1 than group B2.

Patients of group B1 were observed to have more attacks of angina, more ECG changes and more use of Nitrates and lipid lowering drugs than patients of group B2.

HCV +ve patients and HCV -ve patients

There were 67 patients with HCV +ve(A1+B1).42 of them(63%) were discovered to have angiographic documented coronary artery disease.

Whereas, There were 145 patients with HCV –ve(A2+B2).69 of them(47%) were discovered to have angiographic documented coronary artery disease.

And according to the above data, the prevalence of coronary artery disease in HCV patients is higher than its prevalence in HCV –ve patients.

CONCLUSION

The work seems to support the view that chronic HCV infection is a risk factor for atherosclerosis, the development of cardiovascular diseases and significant cardiovascular mortality. However, further well conducted studies are necessary to better assess the impact of HCV on the different cardiovascular conditions .

The pathogenic mechanisms should be further elucidated due to their potential impact on the development of novel therapeutic approaches to prevent and to treat cardiovascular complications in patients with chronic HCV infection

Recommendations Based on the evidence discussed in the present work, we feel it

reasonable to recommend to screen for coronary heart disease all patients with chronic HCV infection. Knowledge of the whole pathologic burden will be of help in making a reasoned decision for the management of chronic HCV infection. In this respect, it is important to underline that existing data seem to indicate that hepatitis C treatment reduces the risk of cardiovascular-related mortality. Future studies should clarify the full impact and the right timing of antiviral treatment in preventing, improving or reversing HCV-related atherosclerosis Especially after the new revolution in the treatment of hepatitis C virus.

  And reflect the priority to treat hepatitis C in both the patients with

coronary heart disease to prevent the severity increase and also the patient without coronary disease to protect them earlier.

And also the importance of checking up the HCV patients for ischemic heart disease.