Liver Injury is Associated with ASCVD, Stroke, and CHF Including Among Those without Viral Hepatitis (B Or C), HIV, Alcohol Abuse and Obesity K. So-Armah, J. Tate, J. Lim, V. Lo Re, V. Marconi, J. Samet, C. Gibert, D. Leaf, A. Butt, M. Goetz, D. Rimland, M. Rodriguez-Barradas, M. Budoff, C. Chang, A. Justice, M. Freiberg,

Traditional ASCVD Risk factors Aging Smoking Hypertension Dyslipidemia Diabetes People get atherosclerotic CVD (ASCVD) because They smoke, have hypertension and other traditional risk factors leading to lipid accumulation in vessel walls, an inflammatory response to this accumulation, plaque formation, arterial narrowing and eventual thrombosis leading to clinical events

Excess ASCVD risk in certain groups Compared to uninfected, HIV+ people have: 40-50% increased risk of AMI 17-40% increased risk of ischemic stroke adjusting for multiple confounders In some high risk groups (eg HIV) these risk factors do not explain the excess risk of ASCVD HIV infected people have 40-50% increased AMI risk and up to 40% increased stroke risk compared to uninfected people adjusting for the risk factors we just talked about Freiberg, JAMA IM 2013 Sico, Neurology 2014 Marcus, AIDS 2014

What Drives Excess ASCVD Risk in HIV? Liver injury Liver fibrosis Liver cirrhosis Immuno-metabolic alterations Gut permeability & Microbial translocation Inflammation & monocyte activation Altered coagulation CVD Atherosclerosis Clinical events Heart failure T-cell subsets imbalance Current thinking points to changes in immunologic and metabolic processes associated with both HIV and atherosclerosis For example persistent viremia may lead to systemic inflammaton and monocyte activation, which accentuates the inflammatory response to lipid accumulation in vessels driving atherosclerosis Additionally, HIV is associated with increased gut permeability allowing microbes and microbial products into the portal and systemic circulation again driving inflammation The T-cell is the main target for HIV and different T-cell subsets control inflammatory responses which we have just said is a driver of atherosclerosis. For this study we wanted to look upstream of these immunologic processes since intervening earlier in the mechanism may be a more effective way to reduce CVD risk Liver injury is common in HIV, The liver regulates lipid metabolism, immune tolerance (T-cells), coagulation, and microbial translocation from portal to systemic circulation, processes associated with CVD risk

Hypothesis Liver injury CVD Fibrosis Cirrhosis CVD Atherosclerosis Clinical events Heart failure Liver injury is independently associated with incident ASCVD events Current thinking points to changes in immunologic and metabolic processes associated with both HIV and atherosclerosis For example persistent viremia may lead to systemic inflammaton and monocyte activation, which accentuates the inflammatory response to lipid accumulation in vessels driving atherosclerosis Additionally, HIV is associated with increased gut permeability allowing microbes and microbial products into the portal and systemic circulation again driving inflammation The T-cell is the main target for HIV and different T-cell subsets control inflammatory responses which we have just said is a driver of atherosclerosis. For this study we wanted to look upstream of these immunologic processes since intervening earlier in the mechanism may be a more effective way to reduce CVD risk Liver injury is common in HIV, The liver regulates lipid metabolism, immune tolerance (T-cells), coagulation, and microbial translocation from portal to systemic circulation, processes associated with CVD risk

VACS VC Overview & Study Design VACS VC (N=133018) Current Study (N=97979) Prospective, observational cohort Enrolled in VACS VC Alive 4/1/2003 (baseline) No prevalent CVD Censor: 1st CVD event, death, 9/30/12 Cox proportional hazards Median follow up 6.8 years HIV+ HIV- To test this hypothesis, we analzed data from the Veterans Aging Cohort Study Virtual cohort This is a longitudinal prospective observational cohort of HIV+ Veterans each matched to 2 uninfected veterans on age, sex, race ethnicity and geographical location In this analysis, participants alive and enrolled as of April 2003, free of CVD at baseline were followed until a CVD event, death or 9/30/2012 We used cox proportional hazards analysis Matched on age, sex, race-ethnicity, geographical location Fultz, Med Care 2006

Exposure: Liver Injury Fibrosis Cirrhosis ICD9 codes FIB4= Age x AST Platelets x ALT0.5 FIB4<1.45 No advanced fibrosis (83% NPV vs. biopsy) Moderate fibrosis FIB4>3.25 Advanced fibrosis (71% PPV vs. biopsy) To define liver injury, We used FIB4 is an index calculated from Age, aspartate and alanine transaminases and platelet count Cirrhosis was identified by ICD9 codes FIB4<1.45: 83% probability of no advanced fibrosis (NPV); 74% sensitivity FIB4>3.25: 71% probability of having advanced fibrosis (PPV) CVD was defined using ICD9 codes for acute myocardial infarction (AMI), coronary heart disease, ischemic stroke and heart failure For Jan – expanded FIB4 to include alt, ast, plt within 180 days of each other and alt within 180 days of baseline http://depts.washington.edu/hepstudy/definitions/?let=c Am J Gastroenterol. 2008 Aug;103(8):1973-80.

Outcomes: ASCVD + CHF Prevalent - EXCLUDED Incident AMI CHD Stroke Unstable angina Revascularization Stroke Congestive heart failure AMI CHD Ischemic stroke Congestive heart failure ASCVD We excluded people with prevalent CVD including AMI, CHD, ischemic or hemorrhagic stroke or heart failure We defined ASCVD to include AMI, CHD and ischemic stroke and examined CHF separately ICD-9 codes from VA, Medicare, VA Fee for Service

Baseline Characteristics Liver fibrosis (no cirrhosis) Cirrhosis (N=1635) Minimal (N=57423) Moderate (N=16067) Advanced (N=2910) Mean age (SD) 47 (9) 54 (9) 53 (8) 52 (7) Female 4 2 1 Race Black 47 53 55 36 White 40 35 33 49 HCV 13 60 68 HIV 29 50 64 44 Alcohol abuse 24 31 46 Heres what the cohort looked like Mean age in the predominantly male cohort was 49. Over half the participants were black Increasing severity of liver injury was associated with greater prevalence of HCV and HIV, and alcohol abuse Missing FIB4 =19926

Baseline Characteristics Liver fibrosis (no cirrhosis) Cirrhosis (N=1635) Minimal (N=57423) Moderate (N=16067) Advanced (N=2910) Current smoker 37 38 46 48 Diabetes 13 15 27 BMI>30 kg/m2 34 22 14 Hypertension 61 67 66 81 LDL≥160 mg/dl 10 6 3 Triglycerides ≥200 mg/dl 21 20 16 HDL<40 mg/dl 39 Those with cirrhosis had greater prevalence of smoking diabetes, hypertension but lower LDL and triglycerides

Liver fibrosis (no cirrhosis) Number of Events Incident CVD events Liver fibrosis (no cirrhosis) Cirrhosis (N=1635) Minimal (N=57423) Moderate (N=16067) Advanced (N=2910) ASCVD 2786 1131 196 104 CHF 2248 1059 222 132

Liver Injury, CVD & Mortality (crude rates) Left axist has incident CVD rates while the right axis has mortality rates Blue bars represent ASCVD, red bars represent CHF and the white line is mortality ASCVD and CHF rates were highest among those with advanced fibrosis or cirrhosis despite the fact that risk of death was highest in these two groups Given the proximity in rates for advanced fibrosis and cirrhosis, and smaller sample sizes in these groups, subsequent analyses will lump them togehter

Liver Injury & CVD Risk Liver injury N=97397 ASCVD Hazard ratio, HR (95% CI) CHF HR (95% CI) Age, race adjusted Fully adjusted* Fully Adjusted* Fibrosis (no cirrhosis) Minimal Ref Moderate 1.1 (1.01-1.2) 1.0 (0.95-1.1) 1.15 (1.1-1.2) Advanced 1.4 (1.2-1.6) 1.1 (0.97-1.3) 1.5 (1.3-1.7) Cirrhosis Yes 1.6 (1.3-2.0) 1.2 (0.99-1.5) 1.8 (1.5-2.1) To orient you, the first 2 columns lists liver injury categories The next two show age, race adjusted and fully adjusted hazard ratios for ASCVD risk The last shows fully adjusted hazard ratios for CHF The fully adjusted analyses were adjusted for age, race-ethnicity, HIV, HCV, HBV, alcohol abuse/dependence, hypertension, diabetes, LDL, HDL, triglycerides, smoking, statin, renal disease, anemia, BMI, cocaine, aFib Increasing severity of liver injury was associated with ASCVD risk in a stepwise fashion in age, race adjusted models After adjustment for confounders these associations were attenuated and no longer statistically significant Liver injury was associated with heart failure in fully adjusted models *Adjusted for age, race-ethnicity, HIV, HCV, HBV, alcohol abuse/dependence, hypertension, diabetes, LDL, HDL, triglycerides, smoking, statin, renal disease, anemia, BMI, cocaine, aFib

Liver Injury & ASCVD Risk Liver status N=97397 Fully adjusted* Hazard Ratio (95% confidence interval) AMI CHD Isch. Stroke Fibrosis (no cirrhosis) Minimal Ref Moderate 1.0 (0.9-1.1) 1.03 (0.9-1.1) Advanced 1.0 (0.8-1.3) 1.1 (0.9-1.3) 1.3 (1.04-1.6) Cirrhosis Yes 1.0 (0.7-1.5) 1.0 (0.8-1.4) 1.4 (1.1-1.9) When we look separately at different types of ASCVD, We found no association of liver njury with AMI or CHD but did find a significant association with the risk of ischemic stroke in fully adjusted models *Adjusted for age, race-ethnicity, HIV, HCV, HBV alcohol abuse/dependence, hypertension, diabetes, LDL, HDL, triglycerides, smoking, statin, renal disease, anemia, BMI, cocaine, (aFib)

Analyses Excluding : HIV, HCV, HBV, Alcohol abuse, Obesity Lastly, to get a better sense of whether the association between liver injury and CVD was independent of confounding, we performed a sensitivity analysis excluding people with HIV, hepatitis C, alcohol abuse/dependence diagnosis, or BMI>30 With this limited sample, we still saw trends where advanced fibrosis or cirrhosis was associated with ACVD, stroke and CHF

Limitations & Next Steps Indirect measure of liver fibrosis Non-adjudicated outcomes Limited generalizability to women Competing risk of non-CVD death Important limitations include our assessment of liver injury only at baseline and the low number of women in the cohort, which may limit the generalizability of these findings. The next step will be to account for competing risk of death

Summary Liver injury Atherosclerosis Fibrosis AMI, CHD Stroke Cirrhosis Atherosclerosis Stroke Heart failure AMI, CHD In summary, Stroke and heart failure risk increase with severity of liver injury Despite competing risk of mortality

Acknowledgements VACS Mentors Funding support Participants Amy Justice Janet Tate Chuck Alcorn Mentors Matthew Freiberg Jeffrey Samet Joseph Lim Joyce Chang Funding support NIAAA U01-AA020790 U24-AA022001 NHLBI R01-HL125032 R01-HL095136

Thank you

CVD & Mean Time to Event (MTTE) Incident CVD Liver fibrosis (no cirrhosis) Cirrhosis (N=1783) Minimal (N=57342) Moderate (N=16036) Advanced (N=2893) ASCVD (#) 2786 1131 196 104 MTTE (SD) 4.6 (2.4) 4.4 (2.4) 4.3 (2.3) 4.2 (2.4) CHF (#) 2248 1059 222 132 4.5 (2.3) 4.1 (2.3) 4.0 (2.4)

Baseline Characteristics Liver fibrosis (no cirrhosis) Cirrhosis (N=1635) Minimal (N=57423) Moderate (N=16067) Advanced (N=2910) Mean age (SD) 47 (9) 54 (9) 53 (8) 52 (7) Female 4 2 1 Race Black 47 53 55 36 White 40 35 33 49 HCV 13 60 68 HIV 29 50 64 44 VL≥500 copies/ml 14 27 38 17 CD4<500 /mm3 16 25 Heres what the cohort looked like Mean age in the predominantly male cohort was 49. Over half the participants were black Increasing severity of liver injury was associated with greater prevalence of HCV and HIV, particularly poorly conrolled HIV Missing FIB4 =19926

Baseline Characteristics Liver fibrosis (no cirrhosis) Cirrhosis (N=1783) Minimal (N=57342) Moderate (N=16036) Advanced (N=2893) BMI>30 kg/m2 34 22 14 Renal disease 4 7 8 Alcohol abuse 24 31 46 68 Cocaine 15 21 25 Statin 30 ART 39 51 This with cirrhosis or advanced fbrosis were less obese, had a greater prevalence of renal disease, alcohol abuse, cocaine in the past year.

Summary CVD rates increase with severity of liver injury Despite competing risk of mortality CVD risk increases with severity of liver injury Largely driven by congestive heart failure (CHF) Stroke risk is elevated with severe liver injury Increased CVD, CHF, and stroke risk with liver injury may be independent of hepatic-comorbidities HIV, HCV, alcohol abuse/dependence, obesity