Hepatitis C virus (HCV) infection is thought to be associated with an increased risk of coronary heart disease (CHD) events, perhaps secondary to increased inflammation. We sought to examine the angiographic burden of coronary artery disease (CAD) in patients with HCV compared to HCV-negative patients. All consecutive HCV RNA–positive patients (n = 61) who underwent coronary angiography at the University of Arkansas for Medical Sciences from 2001 to 2013 were identified. A parallel group of HCV-negative controls (n = 61), matched for age, gender, and indication for coronary angiography served as control. Angiographic burden of CAD was assessed by computing Gensini scores. Statistical analysis was performed using SPSS 21.0. Patients with HCV had significantly lower levels of total and low-density lipoprotein cholesterol. Preangiographic use of aspirin and statin was significantly lower in the HCV cohort. Number of patients with obstructive CAD was less in HCV group (23% vs 39%, p <0.05). However, angiographic Gensini score was similar in both groups. There was no correlation between HCV RNA titers and Gensini score (p = 0.9, analysis of variance). In conclusion, patients with active HCV infection have similar angiographic CAD burden as HCV-negative patients. Furthermore, viral load does not appear to correlate with atherosclerosis burden. Patients with HCV have less-obstructive CAD and less-frequent use of aspirin and statins.
Hepatitis C virus (HCV) is a common chronic infection worldwide. Though various infections have been linked to coronary atherosclerosis, the association between HCV infection and atherosclerotic coronary heart disease (CHD) remains unclear. Some studies have shown an increased incidence of CHD events in these patients, whereas others have proposed that HCV may even have a protective effect against CHD. In a recent large database study, we reported an increased incidence of CHD events in patients with HCV infection and showed that patients with detectable HCV RNA are at much greater risk for CHD compared to patients who are only HCV antibody positive, suggesting that an active HCV infection increases the risk of CHD events. We hypothesized that active infection with HCV may be associated with more extensive coronary atherosclerosis. In this study, we sought to determine the association and correlation between active HCV infection and angiographic burden of coronary artery disease (CAD).
Methods
We conducted this study using the cardiac catheterization laboratory database at the University of Arkansas for Medical Sciences. Active HCV infection was defined as the presence of detectable HCV RNA by polymerase chain reaction. We identified all HCV RNA–positive patients (hereafter referred to as patients with HCV) who underwent coronary angiography form January 2001 to December 2013. Equal number of HCV RNA–negative subjects (hereafter referred to as Controls) matched for age, gender, and indication for coronary angiography were identified. Patients with a history of coronary artery bypass graft surgery were excluded to avoid a falsely high Gensini score as described below. Angiographic CAD was defined as the presence of any coronary stenosis other than minimal luminal irregularities. Obstructive coronary disease was defined as stenosis >50% in at least one major epicardial artery. The study was approved by the institutional review board at our institution.
Data on co-morbidities such as hypertension, diabetes, hyperlipidemia, and chronic kidney disease was collected through individual chart review. Laboratory data collected include hemoglobin (Hb), serum albumin, total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase, alkaline phosphatase, gamma glutamyl transferase, hemoglobin A1c, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides international normalized ratio, and serum creatinine.
Indication for coronary angiography was obtained from the preoperative report. Angiographic data was reviewed by 2 independent investigators (NP and YR). Gensini scoring system was used for angiographic quantification of CAD burden. Gensini system takes into consideration severity of the coronary lesion, location in the epicardial artery, and significance of the myocardial territory at jeopardy. A score is assigned to each lesion based on the severity of stenosis, and a multiplier is applied to each lesion score based on the functional significance of the area supplied by that segment. The final Gensini score is the additive of individual lesion scores. This scoring system has been validated as being a predictor for long-term adverse cardiac events and has been shown to correlate well with multiple other scoring systems in a recent systematic review. This scoring system has not been validated in patients with coronary bypass grafts. Thus, patients with a history of surgery coronary revascularization were excluded from our study.
Statistical analyses were computed with SPSS version 21.0 (SPSS Inc, Chicago, Illinois). Data are reported as mean ± standard deviation. The paired Student t test was used to compare contiguous data. Categorical data were compared with the chi-square test. Analysis of variance was used to describe correlation between HCV RNA titers and Gensini scores. A p value <0.05 was considered statistically significant.
Results
A total of 61 patients with HCV and 61 HCV-negative controls were identified. Baseline characteristics of the patients are listed in Table 1 . Patients in both groups were well matched for age, gender, co-morbidities, smoking status, and indication for coronary angiography. Patients with HCV had significantly lower levels of total cholesterol, LDL cholesterol, and platelets compared to controls. Fewer patients with HCV had hypertension and diabetes than controls. Use of aspirin and statins was also significantly less in this population. One-third of the all coronary angiography procedures were performed for evaluation of atypical chest pain and 1/3 were done on patients after positive results of a noninvasive stress modality. Thirteen percent of patients underwent coronary angiography for acute coronary syndrome (ST-elevation myocardial infarction, non–ST-elevation myocardial infarction and unstable angina). The reminder of the procedures were performed as part of preoperative workup and for evaluation of cardiomyopathy.
| Variable | Hepatitis C RNA positive patients (n=61) | Hepatitis C negative Controls (n=61) |
|---|---|---|
| Age (years) | 52+/-7 | 52+/-7 |
| Women | 24 (39.3%) | 23 (37.7%) |
| Diabetes mellitus | 21 (34.4%) | 26 (42.4%) |
| Hypertension | 39 (63.9%) | 47 (77%) |
| Smokers | 24 (39.3%) | 26 (42.6%) |
| Chronic kidney disease | 11 (18%) | 10 (16.3%) |
| Medications | ||
| Aspirin ∗ | 17 (27.8%) | 34 (55.7%) |
| Beta blockers | 28 (45.9%) | 30 (49.1%) |
| Calcium channel blockers | 15 (24.5%) | 11 (18%) |
| Statin ∗ | 13 (21.3%) | 21 (34.4%) |
| Body mass Index (kg/m 2 ) | 29+/-7 | 31+/- 9 |
| Lipid panel (mg/dl) | ||
| Total cholesterol ∗ | 145+/- 41 | 180+/- 50 |
| Low density lipoprotein cholesterol ∗ | 81+/- 35 | 108+/- 45 |
| High density lipoprotein cholesterol | 42+/- 16 | 41+/- 17 |
| Triglycerides | 122+/- 97 | 162+/- 119 |
On angiographic assessment, incidence of obstructive coronary disease was significantly higher in the control group. However, there was no significant difference between the 2 groups in the number of vessels with obstructive coronary disease ( Table 2 ). Mean Gensini score was 22 ± 27 in the HCV-positive group and 23 ± 24 in the control group. There was no significant correlation between HCV viral load and angiographic Gensini score between the 2 groups (p = 0.9; Figure 1 ).
