Antiviral Therapy Reduces Risk of Cardiovascular Outcomes in Patients with HCV

Dhrubajyoti Bandyopadhyay, MBBS, MD

Credit: ResearchGate

Patients with hepatitis C virus (HCV) using antiviral therapy have a significantly lower risk of cardiovascular outcomes and mortality, according to a recent systematic review and meta-analysis.

Antiviral therapy use was associated with a decreased risk of cardiovascular death, myocardial infarction, all-cause mortality, and peripheral artery disease.¹

“Hepatitis C infections have been shown to be associated a with higher risk of atherosclerotic cardiovascular disease. However, the use of antiviral therapy and the risk of cardiovascular disease has not been well established with limited literature,” wrote investigators.¹

The World Health Organization estimates 58 million people have chronic HCV globally.² Although infection does not always require treatment, antiviral medications are frequently prescribed for chronic HCV to clear the virus from the bloodstream, slow down the progression of inflammation and scarring of the liver, and reduce the chances of developing cirrhosis and liver cancer.³

To assess the association between antiviral therapy use post-HCV infection and cardiovascular outcomes, senior investigator Dhrubajyoti Bandyopadhyay, MBBS, MD, of Massachusetts General Hospital, and a team of investigators conducted a systematic literature search in PubMed, Embase, and Scopus for prospective and retrospective cohort studies of patients ≥18 years of age with HCV. For inclusion, studies were required to have 2 arms and include data for risk of any cardiovascular disease, stroke, peripheral artery disease, myocardial infarction, and all-cause mortality. Reviews, case reports, case series, studies on animals or patients <18 years of age, studies with a single arm or without HCV infection or without antiviral therapy, and studies without outcomes of interest were excluded.¹

The preliminary database search yielded 974 articles, of which 175 studies were excluded after investigators removed duplicates. An additional 778 studies were excluded from the initial screening based on the inclusion and exclusion criteria. Investigators conducted a full-text review for the remaining 21 articles and excluded 13 due to no HCV in participants, no desired outcomes, or having a single arm. In total, 8 studies including 394,452 patients with HCV, 111,076 in the antiviral therapy group and 283,376 in the nonantiviral therapy group, met the eligibility criteria and were included in the meta-analysis.¹

The primary outcome was the risk of any cardiovascular disease. Secondary outcomes of interest included incidences of stroke, peripheral artery disease, myocardial infarction, and all-cause mortality.¹

A pooled analysis of primary outcomes showed antiviral therapy was associated with a reduced risk of any cardiovascular death (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41–0.75; P < .001) compared with the nonantiviral therapy group. Investigators pointed out the risk of all-cause mortality (HR, 0.38; 95% CI, 0.32–0.46; P < .001; I2 = 87.85%), myocardial infarction (HR, 0.62; 95% CI, 0.41–0.94; P = .02; I2 = 4.48%), and peripheral artery disease (HR, 0.62; 95% CI, 0.41–0.93; P = .02; I2 = 13.40%) were also significantly lower among patients using antiviral therapy.¹

High heterogeneity prompted investigators to perform sensitivity analyses for cardiovascular death, all-cause mortality, and stroke. Results of cardiovascular death and all-cause mortality remained significant and unaltered after sensitivity analysis by excluding one study at a time (P < .05), but investigators observed a statistically significant lower risk of stroke among the AVT group compared to the nonantiviral group after excluding a 2022 prospective cohort study (HR, 0.71; 95% CI, 0.60–0.85; P < .001).¹

Subgroup analyses were performed based on the type of antiviral therapy including direct-acting antiviral (DAA) and interferon-based therapy (IBT), with results showing no significant subgroup difference between the 2 for the risk of any cardiovascular death (P = .96). Investigators noted studies using IBT showed a reduced risk of stroke compared to nonantiviral therapy (HR, 0.71; 95% CI, 0.58–0.88) while there was no significant difference among studies using DAA therapy compared to nonantiviral therapy (HR, 0.94; 95% CI, 0.51–0.73).¹

“In our study, we revealed that [antiviral therapy] significantly reduces our primary outcomes i.e., any cardiovascular disease in comparison to the [nonantiviral therapy] group. Secondary outcomes i.e., myocardial infarction, all-cause mortality, and [peripheral artery disease] were also significantly lower in the [antiviral therapy] group as compared to [nonantiviral therapy],” concluded investigators.¹

References:

1. Jaiswal V, Ang SP, Hanif M, et al. Cardioprotective effect of antiviral therapy among hepatitis C infected patients: A meta-analysis. Int J Cardiol Heart Vasc. doi:10.1016/j.ijcha.2023.101270.
2. World Health Organization. Hepatitis C. Newsroom. July 18, 2023. Accessed October 9, 2023. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
3. American Liver Foundation. Treating Hepatitis C. Hepatitis C Information Center. Accessed October 9, 2023. https://liverfoundation.org/liver-diseases/viral-hepatitis/hepatitis-c/treating-hepatitis-c/