Endothelial dysfunction and subclinical atherosclerosis in HIV/HCV- coinfected patients in the Lower Silesia Region, Poland Katarzyna Barska 1,2, Wiesława Kwiatkowska 1,2, Brygida Knysz 1,3, Justyna Drelichowska 1,2, Katarzyna Arczyńska 1, Małgorzata Zalewska 3, Jacek Gąsiorowski 1,3, Wojciech Witkiewicz 1,2 1 Wrovasc Integrated Cardiovascular Centre, Regional Specialist Hospital, Research and Development Center in Wroclaw, Wroclaw, Poland 2 Department of Angiology, Regional Specialist Hospital in Wroclaw, Research and Development Center in Wroclaw, Wroclaw, Poland 3 Department of Infectious Diseases, Liver Diseases and Acquired Immune Deficiences Wroclaw Medical University, Poland
Introduction Epidemiology of HIV/HCV coinfection HCV/HIV coinfection globally 35 mln people are living with HIV HCV/HIV coinfection in Poland 18 204 people have been infected with HIV since 1985 r. 2,1 mln new HIV infection in 2013 1258 new HIV infection in 2013 130-170 mln people infected with HCV 730 000 people infected with HCV 30% people with HIV coinfected with HCV 61,2% people with HIV coinfected with HCV HIV HCV [http://wwwnc.cdc.gov/
Introduction Cardiovascular disease in HIV infection HAART Metabolic abnormalities Lipodystrophy Dysfunction of endothelium CVD risk factors Male gender Smoking cigarettes Life style Diet Since the introduction of HAART, the life expectancy of a person living with HIV has been similar to that of a person who has not acquired HIV There are 4,2 mln people aged 50 and older living with HIV today HIV infection Induction of chronic inflammation Lipids abnormalities notassociated with cart Risk of CVD
Introduction HIV/HCV coinfection and the risk of cardiovascular disease Data regarding impact of HCV on the development of subclinical atherosclerosis in HIV(+) pts are scanty: chronic inflammation metabolic complications higher rates of CVD risk factors There is also a lack of unambiguous reports about the influence of a HCV coinfection on endothelium dysfunction and the advancement of subclinical atherosclerosis in HIV infected individuals. The beneficial impact of HCV coinfection on lipids has led to postulate that HCV coinfection may ameliorate the increased CVD risk associated with HIV infection and HAART use.
Study aims 1. The aim of the study was the assessment of the influence of HCV coinfection on the endothelium dysfunction and the advancement of subclinical atherosclerosis in patients living with HIV. 2. The behaviour of endothelium and haemostasis markers in blood plasma (TNF-α, IL-1, VCAM-1, vwf, TM, TF, TFPI) was also appraised, as well as the influence of traditional cardiovascular risk factors on their levels in HIV/HCV-coinfected patients. 3. The influence of endothelium dysfunction and haemostasis markers on the advancement of subclinical atherosclerosis was analysed, by measuring the intima-media thickness of carotid arteries of HIV/HCVcoinfected patients.
Material & Methods Study group: 121 HIV-infected individuals (41 women and 80 men), residents of Lower Silesia, treated at the Acquired Immunodeficiency Clinic in Wroclaw, Poland. Two subgroups were created: 1. Patient infected with HIV/HCV coinfection - HIV(+)/HCV (+) - 66 pts 2. Patient infected with HIV without HCV coinfection - HIV(+)/HCV(-) - 55 pts Control group: 42 healthy individuals (residents of the same region as the cohort), respectively matched for age and gender, generally fit, with no experience of cardiovascular events. In all subjects in the control group HIV, HBV and HCV infections were ruled out.
Material & Methods Study protocol 1. The respondent's informed consent to participation in the study 2. Medical history - occurance of cardiovascular diseases - traditional cardiovascular risk factors - cumulative treatment time of antiretroviral treatment - HIV infection data 3. Physical examination - anthropometric measusrments, resting ECG - angiological tests
Material & Methods 4. B-mode ultrasound of the carotid arteries Assesed parameters: Carotid intima-media thickness (cimt) Prevalence of atheroclerotic plaque
Methods 5. Laboratory studies: After 14 hours of fasting, blood was collected for laboratory testing, performed by standard laboratory methods: - parameters associated with CVD risk factors haematology test, concentrations of aminotransferases, creatinine, glucose, total cholesterol, HDL, LDL, non-hdl fraction, triglycerides, fibrinogen, D-dimers, wrcrp, insulin, HOMA-IR - parameters associated with HIV, HBV, HCV infection current CD4 cell count, anti-hiv antibodies, HIV RNA anti-hbc, anti-hbs antibodies, HBsAg HCV RNA
Material & Methods Pro-inflammatory cytokins, markers of endotheluim dysfunction and haemostasis: Plasma levels of tested markers was determined by enzyme immunoassay (ELISA) of the citrate plasma with a reagent kit for: TNF-α IL-1β tumor necrosis factor-α interleukin-1β VCAM-1 vascullar cell adhesion molecule 1 vwf stm TF TFPI von Willebrand factor soluble thrombomodulin tissue factor tissue factor pathway inhibitor
Results Progression of carotid subclinical atherosclerosis was similar in HIV/HCVcoinfected pts and HIV-monoinfected pts; both subgroups exhibited greater atherosclerotic changes as compared with the healthy control group. cimt HIV monoinfection (p=0,0003) HIV/HCV coinfection (p=0,0003) No significant differences were found among subjects in the control group, HIV-monoinfected and HIV/HCV-coinfected subgroups frorn the presence of atherosclerotic plaque (p=0,11, chi-square test) No influence of HCV coinfection in HIV positive pts on the development of subclinical atherosclerosis was observed.
Cardiovascular risk profile: HIV-monoinfected and HIV/HCV-coinfected subgroups Results
Results The impact of cardiovascular risk factors on the severity of subclinical atherosclerosis cimt HIV (+) / HCV (-) Age (p<0,0001) Pack-years (p=0,0002) Cumulative ARV treatment (p=0,02) Cumulative NRTI (p=0,05) Hypertension (p=0,06) HIV (+) / HCV (+) Age (p<0,0001) Non-HDL cholesterol (p=0,0004) Cumulative ARV treatment (p=0,005) Cumulative NRTI (p=0,01) Cumulative PI (p=0,005) Pack-years (p=0,09)
Results The impact of HCV-coinfection on the endothelial dysfunction HCV-coinfection significantly increased the concentration of VCAM-1, stm, vwf Markers (1) HIV(+)/HCV(-) n=55 (2) HIV(+)/HCV(+) n=66 (K) Control group n= 42 p-value Post hoc VCAM -1 [pg/ml]* 1273 (1054-1606) 1667 (1185-2327) 891,8 (752,4-1058,5) <0,0001 stm [ng/ml]* 3,3 (2,93-3,98) 3,8 (3,15-4,9) 3,6 (3,1-4) 0,01 K vs 1 p=0,0001 K vs 2 p=0,0001 1 vs 2 p=0,026 K vs 1 p=1,0 K vs 2 p=0,18 1 vs 2 p=0,009 HIV-monoinfected patients had significantly higher levels of VCAM-1 than the control group (p < 0.0001). vwf [U/dl]* 129,6 (95,92-166,95) 171,3 (118,3-243) 114,8 (87-154,8) 0,001 K vs 1 p=0,59 K vs 2 p=0,001 1 vs 2 p=0,033
Results Impact of proinflammatory cytokins on endothelial dysfunction markers TNF-α IL-1β VCAM-1 (p=0,036) stm (p=0,02) stm (p=0,012) Cross-correlation of endothelial dysfunction markers
Results Impact of traditional CVD risk factors on the endothelial function in study group (multivariate regression) Tested markers TNF-α IL-1β VCAM-1 stm vwf TF TFPI CVD risk factors Age (p=0,001) Gender (p=0,038) Triglicerydes (p=0,045)* BMI (p=0,018)* Gender (p=0,022) Hypertension (p=0,01) Age (p=0,017) Gender (p=0,04) HDL cholesterol (p=0,047)* Positive CVD family history (p=0,048)* Fibrinogen (p=0,018) None Total cholesterol (p=0,002) Non-HDL cholesterol (p=0,018) LDL cholesterol (p=0,008) Cardiovascular risk NCEP ATPIII (p=0,048)
Results Effects of the status of virological and immunological parameters, and the correlation with antiretroviral treatment time on the concentration of endothelial and haemostasis markers The negative, independent effect was demonstrated of current HIV RNA and nadir CD4+ T-cell count on concentration of TF and TFPI. Strong independent effect of cumulative ARV treatment time and NRTI, NNRTI, PI treatment time was recorded on higher concenration of TF. Concentrations of TF (p=0,0017) and TFPI (p=0,006) were higher in patients with undetectable HIV RNA
Effect of endothelial and haemostasis markers on the development of subclinical atherosclerosis Results In a studied cohort only TF and TFPI exhibited a positive correlation with cimt (p=0,042, p=0,024) No significant relationship was found between the other investigated markers and the advanced of subclinical atherosclerosis.
Results Characteristic of subgroups based on the plasma level of TF Age (years)* 0,02 cimt, (mm)* 0,036 TF >450 pg/ml Hypertension, n% 0,035 Cardiovascular risk ATP III* 0,059 Duration of HIV infection, (years)* 0,059 Current CD4+ T cells (cells/μl) * 0,03 Nadir CD4+ T cells, (cells/μm)* 0,086 Undetectable HIV RNA, n (%) 0,026 HIV RNA zenith (copies/ml)* 0,07 Duration of treatment ARV, (years)* 0,002 Cumulative NRTI treatment time ( years)* 0,008 Cumulative PI treatment time( years)* 0,006 Cumulative ARV treatment time ( years)* 0,003
Conclusions 1. HCV coinfection in HIV positive patients did not influence development of subclinical atherosclerosis 2. The cardiovascular risk was lower amongst patients with a HCV coinfection, and the behaviour and importance of traditional cardiovascular risk factors was different when compared with HIV-monoinfected patients - lower levels of atherogenic lipids, tobacco smoking more often and a less frequent presence of hypertension was observed 3. In HIV/HCV-coinfected patients, the development of subclinical atherosclerosis is influenced by age, levels of non-hdl cholesterol, cumulative PI, NRTI and antiretroviral treatment time. A tendency related to tobacco smoking is also observed. Tobacco smoking, similarly to hypertension (but not non-hdl cholesterol), cumulative NRTI and ARV treatment time has a strong influence on the development of atherosclerosis in the HIV-monoinfected patients.
Conclusions 4. In HIV positive pts exacerbated endothelial dysfunction was observed, but only HCV coinfection influenced high blood levels of endothelial dysfunction markers: VCAM-1, vwf and stm. These results can indicate HCV involvement in thr development of CVD in HIV/HCV positive pts. When investigating CVD in HIV positive pts, HCV coinfection should be also considered. 5. The TF plays a part in the pathogenesis of atherosclerosis and its high concentrations in the blood ought to be considered a predictive factor of the increased development of subclinical atherosclerosis in HIV-infected people; conversely, HIV patients with higher cimt values may exhibit an enhanced procoagulant state. Particular attention is required in the area of cardiovascular prevention, including consideration of antiplatelet therapy in those HIV patients with higher cimt values, diagnosed arterial hypertension, long-term cumulative antiretroviral NRTI and PI therapy and a low nadir CD4+ T-cell count. Similar relationships are demonstrated by TFPI, higher levels of which are associated with higher cardiovascular risk.