Beneficial effects of DAAs on cardiac function and structure in hepatitis C patients with low‐moderate liver fibrosis

Hepatitis C virus (HCV)‐related chronic infection has been associated with a higher incidence of cardiovascular diseases. An altered morphology and function of both left and right heart have been described in HCV patients; however, the causality of the association is still debated. Ninety‐eight nonobese and nondiabetic HCV patients (59.5 ± 12.0 years; males 52%) with Fibroscan‐Transient Elastography assessed low‐moderate liver fibrosis that achieved sustained viral response at 12 and 24 weeks after DAAs (direct‐acting antivirals) participated. 56 were matched with 52 control subjects for age, sex and cardiovascular risk factors at baseline. A trans‐thoracic echocardiography was performed in each subject at baseline (T0) and repeated in all HCV patients after eradication (6 months later eligibility, T1). TNF‐α and IL‐10 were measured at baseline and at T1. A concentric remodelling of the left heart in HCV participants was identified, whereas tricuspidal annular plane systolic excursion, right indexed atrial volume, right basal ventricular diameter, inferior vena cava diameter and pulmonary arterial pressure were higher in HCV participants compared to matched controls. After virus eradication, left indexed atrial volume and all right cardiac chambers measures were lower than baseline. A significant reduction of TNF‐α was shown at T1, while IL‐10 did not change. This study shows a concentric remodelling of the left ventricle and structural modifications in the right sections in HCV patients compared to controls. Virus eradication with DAAs was associated with a reduction of the main right atrioventricular parameters indicating a direct involvement of the HCV in cardiac changes.

Keywords: DAAs; echocardiography; HCV

• Abbreviations
• ACS acute coronary syndromes
• BSA body surface area
• CAD coronary artery disease
• CVD cardiovascular disease
• DAAs direct‐acting antivirals
• DBP diastolic blood pressure
• ECLIA electro‐chemiluminescence immunoassay
• EDD end‐diastolic diameter
• EF ejection fraction
• ES end‐systolic
• HCC hepatocellular carcinoma
• HCV Hepatitis C virus
• HDL high‐density lipoproteins
• IQR interquartile range
• IVC inferior vena cava
• IVS interventricular septum
• LAV left atrial volume
• LoD limit of detection
• LVMi left ventricular mass/BSA
• MAPSE mitral annular plane systolic excursion
• MDD minimum detectable dose
• PAP pulmonary arterial pressure
• PWT posterior wall thickness
• RAV right atrial volume
• RVD basal right ventricle diameter
• RWT Relative wall thickness
• SBP systolic blood pressure
• SD standard deviation
• TAPSE Tricuspidal annular plane systolic excursion
• TNF‐α Tumour necrosis factor‐α
• TTE trans‐thoracic echocardiography
• URL upper reference limit

Hepatitis Virus C (HCV) infection is among the most common causes of chronic liver disease, liver cirrhosis and hepatocellular carcinoma (HCC).1 It has been estimated that about 1.6% of the worldwide general population carries antibodies against HCV (anti‐HCV positive) and 1.1% has detectable HCV‐RNA levels in the blood.2 In Italy, the rate of HCV infection is between 1.2% and 5.4%.2

In addition to the well‐known deleterious effects on the liver structure and function, HCV‐related chronic infection is associated with other serious extra‐hepatic manifestations, such as mixed cryoglobulinemia, glomerulonephritis, pulmonary fibrosis, autoimmune diseases, dermatological and ocular involvement and non‐Hodgkin B‐cell lymphoma, whose pathogenetic mechanism is probably related to the persistent stimulation of the immune system and the tropism of the virus for other tissues.3,4 Most recently, HCV infection has been even associated with metabolic effects, specially diabetes and insulin resistance,5 atherosclerosis and cardiovascular disease (CVD).6 A reduced insulin sensitivity and chronic hyperglycaemia were indicated as possible co‐factors in determining liver steatosis, severity and progression of fibrosis, development and growth of HCC and reduced response to antiviral drugs.7 Chronic hepatitis C has been also associated with higher risk of carotid intima‐media thickening and carotid artery plaques,8 increased incidence of coronary artery disease9 (CAD), acute coronary syndromes9 (ACS) and cerebrovascular events, such as stroke,10 suggesting that HCV could be considered as a new cardiovascular risk factor.11 In fact, some authors hypothesized that HCV infection might contribute to the atheromatous process12 mainly through chronic inflammation, increased oxidative stress, insulin resistance11 and virus replication on pre‐existing plaques.13 Moreover, there are few studies evaluating the possible deleterious effects of HCV infection on both the right and left heart, but the results are still contradictory.14‐16 Dilated and hypertrophic cardiomyopathy have been recently described as an extra‐hepatic morbidity of HCV infection17 but their real frequency is still not known.18 The pathogenesis of this phenomenon is not completely understood, but HCV cardio‐tropism,19 the release of pro‐inflammatory cytokines20,21 and an abnormal immune response17 were hypothesized as the main putative determinants. In study by Demir et al,14 pulmonary arterial pressure (PAP) vascular resistance and right ventricular and atrial diameters were higher in HCV patients compared to controls, suggesting also the right side of the heart to be impaired. Furthermore, pegylated‐interferon α plus ribavirin (Interferon‐Based Therapy, IBT) and DAAs‐based therapies were shown to significantly improve CVD outcomes.22,23 However, few studies exist about the effects of the IBT and the new direct‐acting antivirals (DAAs) on cardiovascular system after virus eradication. In fact, although HCV elimination has been associated with general improvement in extra‐hepatic comorbidities, particularly in insulin sensitivity,24 the real benefit of antivirals on cardiomyopathy, especially regarding DAAs, has not been clearly defined yet.

The aim of our study was to evaluate the effect of HCV infection on cardiac function and structure, evaluated by trans‐thoracic echocardiography (TTE), and to assess the effect of DAAs on cardiac structure and function abnormalities.

This study was approved by the Ethical Committee of Verona (CESC1746). All subjects signed a written informed consent. Patients involved in this single centre, prospective, observational study were selected from our outpatient clinic (Liver Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata of Verona). The inclusion criteria were a diagnosis of HCV chronic infection and a Fibroscan‐documented low‐moderate liver fibrosis (F0‐F1‐F2, as defined as Liver Stiffness Measurement values lower than 9.5 kPa). Patients with severe liver fibrosis, cirrhosis and HCC were excluded along with subjects with other causes of chronic liver disease, such as alcohol abuse and/or hepatotoxic drugs, metabolic disorders, HBV infection, autoimmune diseases, obesity (BMI, body mass index >30 kg/m2), chronic or acute kidney disease (GFR, glomerular filtration rate <50 mL/min estimated by the Crockroft‐Gault formula), diabetes, uncontrolled hypertension, chronic heart failure and major CV events (such as stroke, previous myocardial infarction, severe peripheral arterial diseases). Between January 2018 and April 2019, 101 HCV patients consecutively referred to our hepatology outpatients clinic for virus eradication agreed to participate to the present study. Three of them were excluded because failed to achieve sustained viral response after 12 weeks (SVR12). Patients were evaluated before (T0) and after virus eradication with DAAs (T1, six months later the beginning of antiviral therapy). All HCV patients were evaluated for liver fibrosis using Fibroscan before viral eradication according to EASL clinical guidelines. A small proportion of them (17 subjects) repeated Fibroscan after SVR in order to re‐establish the fibrosis grade after normalization of transaminases. The operator performing the echocardiography was a member of a different outpatient clinic and, therefore, he made the measurements blind at time 0, and after 6 months of DAAs treatment, because he was not aware of the identity of patients enrolled in this study.

A smaller group of patients with no liver disease, who had previously referred to our hypertension outpatient clinic and had undergone echocardiography by the same blinded sonographer and blood tests according to the same protocol, served as control population. In order to match cases and controls for age, sex and the main cardiovascular risk factors (hypertension, BMI, smoke status, blood cholesterol), we had subsequently to exclude 42 HCV patients from the case‐control study leaving 56 out of 98 HCV patients for the analysis. At baseline, after verifying inclusion and exclusion criteria, anthropometric parameters were measured and viral load, medical history and use of drugs were recorded. Then, cardiovascular examinations were performed followed by venous sampling. Baseline echocardiographic parameters obtained from HCV patients were compared to controls. Subsequently, the entire HCV hepatitis group's parameters (echocardiographic and blood test data) were compared to those obtained after 6 months after beginning of therapy. High‐sensitive Troponin T (HS‐TnT), N‐terminal B‐type natriuretic peptide (NT‐proBNP), interleukin‐10 (IL‐10) and tumour necrosis factor‐α (TNF‐α) concentrations were measured in HCV participants at baseline and T1.

Hypertension was defined as a systolic blood pressure (SBP) values at least 140 mm Hg and/or diastolic blood pressure (DBP) values at least 90 mm Hg, or use of antihypertensive medication.25 Dyslipidemia was defined as follows: either total cholesterol >190 mg/dL or low‐density lipoproteins LDL cholesterol >115 mg/dL or high‐density lipoproteins (HDL) cholesterol <45 mg/dL or triglycerides >150 mg/dL,26 or the use of anti‐lipemic drugs.

Blood Pressure was measured with an oscillometric device (TM‐2501, A&D instruments Ltd., Abingdon Oxford, UK) in a clinostatic position and at rest; three BP measurements taken 5 minutes apart were averaged.

A trans‐thoracic echocardiography (Esaote MyLab™40) was performed in all participants by a single expert sonographer. In parasternal long‐axis view, M‐mode method was used to measure diastolic interventricular septum (IVS) and posterior wall thickness (PW). Through apical four‐chamber view, M‐mode method permitted to detect Mitral annular plane systolic excursion (MAPSE) and Tricuspidal annular plane systolic excursion (TAPSE). Left ventricular diameters and volumes—end‐systolic (ES) and end‐diastolic (ED); diameter (D), volume (V)—and right basal ventricular diameter (RVD) were calculated by B‐mode echocardiography together with atrial volumes—right atrial volume (RAV), left atrial volume (LAV)—in apical four‐chamber view. All volumes were indexed per body surface area (BSA, obtained with the Mosteller formula). Ejection fraction (EF) was calculated through the formula (EDV‐ESV)/EDV. E/A ratio was calculated with pulsed Doppler on mitral annular plane. Continuous Doppler on tricuspidal annular plane in addition to inferior vena cava (IVC) diameter and respiratory variation visualized from the subcostal window were used to estimate pulmonary systolic arterial pressure (PAP). Relative wall thickness (RWT) was calculated through the following formula: (PW/end‐diastolic diameter)*2. Devereux equation was used to obtain left ventricular mass (LVM = 0.80*1.04 [(end‐diastolic diameter + PW + IVS)3 – end‐diastolic diameter3] + 0.6 gr).

Blood was drawn in vacuum tubes containing no additives (Vacutest Kima, Kima, Arzergrande, Padova, Italy). After centrifugation at 1500 g for 10 minutes at room temperature, serum was separated, stored in aliquots and kept frozen at −80°C until measurement.

The concentration of high‐sensitive Troponin T (HS‐TnT) was measured with a fully automated electro‐chemiluminescence immunoassay (ECLIA) on Cobas e801 (Roche Diagnostics, Mannheim, Germany). The limit of detection (LoD), 99th percentile upper reference limit (URL) and the value with 10% imprecision of this method are 3, 14 and 13 ng/L, respectively.27

The concentration of N‐terminal B‐type natriuretic peptide (NT‐proBNP) was also measured with a second generation, fully automated ECLIA on Cobas e801 (Roche Diagnostics, Mannheim, Germany). The LoD for this assay was 5 ng/L. The total imprecision of this method is <10% at 20 ng/L and <3% at 150 ng/L.28 The accepted cut‐off of the Laboratory of the 'Azienda Ospedaliera Universitaria Integrata, Verona' was as follows: HS‐TnT = 14 ng/L, NT‐proBNP = 350 pg/L.

Interleukin‐10 (IL‐10) serum levels were measured using the IL‐10 Quantikine ELISA Kit (R&D Systems, Inc, Minneapolis, MN, USA), according to manufacturer's instructions. All samples were run in duplicate. The minimum detectable dose (MDD) of this method is 3.9 pg/mL, as quoted by the manufacturer. The reported intra‐ and inter‐assay precision were <5% and <8%, respectively.

Tumour necrosis factor‐α (TNF‐α) serum levels were measured using the TNF‐α Quantikine ELISA Kit (R&D Systems, Inc, Minneapolis, MN, USA), according to manufacturer's instructions. All samples were run in duplicate. The MDD of this method ranged from 2.09‐6.23 pg/mL, as quoted by the manufacturer. The reported intra‐ and inter‐assay precision were <3% and <8.5%, respectively.

For both IL‐10 and TNF‐α ELISA kit, a standard curve was generated by plotting absorbance versus log concentration using a four‐parameter logistic curve fit.

Continuous variables are expressed as mean ± standard deviation (SD) and as median with interquartile range (IQR) depending on the data distribution; discrete variables are expressed as number and percentage. Comparison between continuous variables was performed using Student's t test for unpaired data and/or the Mann‐Whitney U test, depending on the distribution of the data. Comparison between continuous variables measured longitudinally in each participant was performed using Student's t test for paired data and/or Wilcoxon rank test, depending on the normal distribution of the data. Correlations were assessed using the Pearson or Spearman test dependently on the data distribution. A stepwise multivariate linear regression analysis was performed in order to determine if any baseline anthropometric, anamnestic and clinical variables (age, sex, BMI, mean arterial pressure, diabetes, dyslipidemia and viral load) could be independently associated with heart modifications (ΔT1‐T0 of RAV/BSA, RVD, TAPSE, PAP, ICV diameter).

In regard to the statistical power of the study, based on previous literature regarding TAPSE after viral eradication (Demir et al) and considering TAPSE being normally distributed in each group with a median standard deviation (SD) of 5 mm, we estimated the need to include at least 44 patients and controls to reveal a difference in TAPSE greater than 2.5 mm with a statistical power of 0.9 (The Type I error probability associated with this test of this null hypothesis is 0.05).

A statistically significant value was considered if a P < .05. SPSS Statistics 22 and GraphPad Prism 7 were used for all data analysis.

Fifty‐six HCV infected participants (males 56.4%; age 59.6 ± 12.4 years) with low‐moderate liver fibrosis (F0‐F1‐F2, LSM ≤ 9.5) were compared with 52 no‐HCV controls (males 53.8%, age 58.8 ± 11.7 years). The characteristics of the two groups are shown in Table 1. No significant differences in age, BMI, prevalence of hypertension, dyslipidemia, smoke status and use of antihypertensive drugs were found; furthermore, none assumed bronchodilators when examined. Only systolic blood pressure (SBP) was higher in the control group.

1 TableComparison between baseline characteristics of HCV participants and controls

1 Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; HDL, high‐density lipoproteins; LDL, low‐density lipoproteins; SBP, systolic blood pressure.

When analysing left heart parameters, a statistically significant difference was found for IVS, PW thickness and end‐diastolic ventricular diameter (Table 2) but not for MAPSE, EF and E/A ratio (Table 2). LVM indexed per body surface (LVMi) tended to be higher in controls, although the difference was not statistically significant. Moreover, when stratified by sex, the average LVMi was within normal range. RWT was higher in HCV patients whereas LAV/BSA was similar (Table 2).

2 TableComparison between baseline echocardiographic parameters in HCV and control groups

2 Abbreviations: BSA, body surface area; EDD, end‐diastolic diameter; EF, ejection fraction; IVC, inferior vena cava; IVS, intraventricular septum; LAV, left atrial volume; LVMi, left ventricular mass/BSA;MAPSE, mitral annular plane systolic excursion; PAP, pulmonary arterial pressure; PWT, posterior wall thickness; RAV, right atrial volume; RVD, basal right ventricle diameter; RWT, relative wall thickness; TAPSE, tricuspid annular plane systolic excursion.

About the cardiac right sections, RAV/BSA and RVD were found to be higher in HCV participants as compared to controls (Table 2). TAPSE, even though within the normal range, PAP and IVC diameter were significantly higher in HCV participants than controls (Table 2). Furthermore, a positive correlation was found between TAPSE and RAV/BSA (r = .354, P = .002).

When subdivided according to viral load (cut‐off: 800 000 copies per millilitre) and liver fibrosis grade, echocardiographic parameters were not differently distributed into sub‐group (Data not shown).

The total group of HCV infected participants (98 subjects, males 52.6%, age 58.2 ± 12.3 years) was evaluated both at baseline (T0) and after starting virus eradication by DAAs (at SVR‐24, 6 months later, T1). Baseline characteristics are shown in Table 3. In particular, none of the smokers has stopped or assumed bronchodilator drugs during the study period (Table 3). Patients were treated with sofosbuvir/velpatasvir (38%), ombitasvir/paritaprevir/ritonavir plus dasabuvir (25.3%), grazoprevir/elbasvir (30.4%) and daclatasvir/sofosbuvir (6.3%) based‐regimens. All subjects enrolled achieved a 12 and 24‐week SVR. Regarding liver fibrosis, 16.3% had grade 0, 59.2% grade 1 and 24.5% grade 2; at baseline the medium value of liver fibrosis by Fibroscan was 6.1 ± 2.4 KPa. There was no significant difference in Fibroscan values in the small group of participants who were re‐evaluated for liver fibrosis at 24‐week SVR (n = 17, 6.1 ± 2.4 KPa vs 5.9 ± 1.8 KPa, P = .610). As relate to HCV genotype, 58.9% had type 1, 16.6% type 2, 15.7% type 3 and 8.8% type 4. Regarding cardiac left sections, EDD and LAV/BSA were found to be higher at baseline compared to T1 as shown in Table 3. Nevertheless, LVMi was significantly reduced after DAAs. RAV/BSA was significantly higher before virus eradication (Table 3); similarly, at T1, RVD was lower than baseline (Table 3). Both PAP and IVC diameter decreased significantly at T1 when compared to baseline (Table 3). On multivariate linear regression analysis, all cardiac modifications (Δ from T0 and T1) were not significantly associated with baseline anthropometric, metabolic and viral status.

3 TableComparison between echocardiographic parameters at baseline and after virus eradication at 6 mo follow‐up

3 Abbreviations: BSA, body surface area; EDD, end‐diastolic diameter; EF, ejection fraction; IVC, inferior vena cava; IVS, intraventricular septum; LAV, left atrial volume; LVMi, left ventricular mass/BSA; MAPSE, mitral annular plane systolic excursion; PAP, pulmonary arterial pressure; PWT, posterior wall thickness; RAV, right atrial volume; RVD, basal right ventricle diameter; RWT, relative wall thickness; TAPSE, tricuspid annular plane systolic excursion.

No significant differences in both HS‐TnT and NT‐proBNP were found between baseline and T1 (HS‐TnT, 6.0 [4.0‐8.0] ng/L at T0 vs 6.0 [4.0‐9.0] at T1, P = .862); (NT‐proBNP, 71.0 [48.7‐143.5] pg/L at T0 vs 69.9 [47.7‐140.7] pg/L at T1, P = .812). Twelve per cent of HCV patients had higher HS‐TnT and NT‐proBNP plasma levels compared to the accepted cut‐off.

Plasma TNF‐α and IL‐10 were measured in 42 participants; in 19 and 13 subjects, the cytokine level was under the minimum detectable dose. However, TNF‐α turned out to be significantly reduced from baseline to the virus eradication at T1 (23 participants: 26.1 [16.5‐45.6] pg/mL at T0 vs 14.6 [9.0‐14.8] pg/mL at T1, P = .002), while IL‐10 did not change in the two different study points (29 participants: 11.1 [8.5‐15.4] pg/mL at T0 vs 6.8 [6.8‐10.8] pg/mL at T1, P = .07).

Recently, a significant benefit of HCV treatment with IBT or DAAs on the incidence and the risk for CV events has been documented in a large study population.29 However, in the large heterogeneous cohort described by Butt et al some limitations emerge, especially regarding the retrospective observational design of the study.29 For the first time, our prospective study shows that HCV patients with low‐moderate liver fibrosis grade, compared to a control group matched for traditional cardiovascular risk factors, age, sex and BMI, have echocardiographic findings of cardiac dysfunction and that these changes are reversible after eradication of HCV by DAAs therapy. Patients with obesity and diabetes were excluded since these conditions may lead to marked structural and functional cardiac changes. However, we have to take into account that this matching cannot be perfect and as a consequence of that IVS and PW were higher in controls than in HCV patients. This could be due to the better control of hypertension in the HCV group, despite the similar prevalence and the use of BP lowering drugs in both groups.

Few studies reported an impairment of left systolic and diastolic function due to HCV infection. In our case, LVMi and EF were not significantly different in the two groups, in contrast with Demir's study which showed an eccentric remodelling with reduced systolic function in HCV patients compared to healthy controls.29 In another study by the same Turkish group, markers of diastolic dysfunction as E/A ratio and E/Em were found altered in infected patients.15 In our study, E/A ratio was not dissimilar in the 2 assessed sub‐populations. Moreover, we did not find differences in MAPSE and LAV/BSA, confirming that an overt left heart systolic and diastolic dysfunction could be excluded.

However, we observed that RWT, beyond being significantly higher in HCV patients than controls, largely exceeded the cut‐off value considered for cardiac remodelling (currently set at 0.42), suggesting a concentric remodelling of the left heart in HCV participants. Unexpectedly and despite an apparent better performance of the left ventricle as compared to controls, we observed a significant enlargement of both right atrium and ventricle, similarly to Demir's study.14 Additionally, IVC diameter and systolic pulmonary arterial pressure was higher in HCV patients, although without differences in terms of smoke status, use of bronchodilators or previous diagnosis of pulmonary diseases. However, recent studies proposed a relationship between HCV chronic infection and pulmonary fibrosis, COPD and other inflammatory lung diseases,30‐32 conditions potentially associated with pulmonary arterial hypertension and right heart failure. Despite morphological parameters appeared to demonstrate a right heart dysfunction, TAPSE was found to be significantly higher in HCV subjects, suggesting a compensatory hyperkinesia of right ventricular walls in response to an upstream venous stasis and pulmonary hypertension.

During the follow‐up, we also evaluated the effect of the virus eradication by DAAs on the cardiac function. A significant decrease of EDD and LVMi was identified in the left chambers after the treatment while EF, IVS and PW did not change from baseline. We hypothesized that this reduction could be secondary to a subclinical left volume overload because of either an increased venous blood return or a subclinical left cardiomyopathy not detectable by EF.

Interestingly, RAV/BSA, RVD, TAPSE, IVC diameter and PAP decreased significantly when compared to baseline without differences in terms of pulmonary drugs assumption or smoking cessation; this finding not only suggests the reversibility of cardiac involvement after the virus eradication, but also underlines the direct role of HCV through multiple pathways. In fact, as mentioned above, HCV is responsible for cardiac and vascular remodelling through direct cytotropic toxicity and an indirect immune‐mediated mechanism, probably both eliminated when the virus is eradicated. The reason why the right chambers are more sensitive to a HCV‐related impairment is not clear and an hemodynamic and/or biochemical mechanism might be involved.14 Chronic liver disease, although with low‐moderate fibrosis, could be associated with a subclinical portal hypertension and may lead to a mild hepato‐pulmonary syndrome. Moreover, a reduced clearance or an inappropriate release of toxic molecules and cytokines by the liver could reach the right chambers in a higher amount. In our cohort, the baseline fibrosis grade was very low and, despite a low number of repeated Fibroscan after SVR, no differences were found in term of hepatic fibrosis after viral clearance, suggesting that the role of hemodynamics of right heart inflow is probably not very important in determining the cardiac involvement observed. After the virus eradication, no significant differences in both HS‐TnT and NT‐pro BNP were found compared to baseline, in contrast with the hypothesis of a direct HCV cytotoxic damage or myocardial stretching. Nevertheless, a small but significant percentage of participants showed high values in both HS‐TnT and NT‐pro BNP, suggesting that, at least in some cases, a direct virus‐related cardiac toxicity could be involved; however, only myocardial biopsies could reveal the role of myocarditis in HCV patients but they are difficult to obtain. Moreover, in participants with a detectable cytokines concentration, we observed a significant decrease of TNF‐α, which is known to be a potent pro‐inflammatory molecule with cardio‐toxic effect.33

No significant changes in IL‐10 concentration were seen; however, IL‐10 is known to have some controversial effects on the immune system, since its contribution to the anti‐inflammatory cascade on one hand and its possible role in T‐lymphocyte exhaustion in chronic viral infections on the other.34 In this setting, the regression of the heart changes we documented in HCV participants after eradication could be related to the decrease of the negative inotropic and pro‐apoptotic properties of TNF‐α, although a significant decrease of cardiac enzymes, as surrogates of myocardial cytolysis or dysfunction, was not found in our cohort.

A limit of our study is the need for a more specific evaluation of systolic and diastolic dysfunction. Further tests, such us spirometry, are required to assess pulmonary function in HCV patients. Moreover, a noninvasive evaluation of liver fibrosis after DAAs could be necessary for better understand the role of liver fibrosis on cardiac remodelling. Baseline HS‐TnT and NT‐pro BNP of controls were unavailable, and this did not allow the comparison between healthy and HCV participants. Finally, only a small percentage of subjects had available plasma samples for cytokines dosage and, among them, a large number of participants were shown to have undetectable levels.

In conclusion, our study is the first‐one comparing an HCV‐population to a control group with similar CV risk factors. In particular, the study shows a concentric remodelling of the left ventricle and structural modifications in the right sections as higher atrial volumes and ventricular diameters as well as a higher pulmonary pressure in HCV patients with low‐moderate liver fibrosis compared to controls. These findings were not linked to the degree of liver fibrosis considered. Furthermore, virus eradication with DAAs was associated with a reduction of the main right atrioventricular and vascular parameter (atrial volume, ventricular diameter, TAPSE, pulmonary pressure and vena cava diameter) indicating a direct involvement of the HCV virus in cardiac changes, reversible after aetiological treatment.

All these findings suggest on one side, the need of cardiac monitoring during HCV chronic infection and, on the other, the beneficial effects of the antiviral treatment on HCV‐related cardiac morbidities also in patients with low fibrosis. Further studies are needed to confirm our findings and to understand the molecular pathogenesis of cardiac involvement during HCV infection.

We thank our colleagues of the Liver Unit of the Azienda Opsedaliera Universitaria Integrata of Verona for great support they gave us in conducting this study.

We wish to confirm that there are no known conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing, we confirm that we have followed the regulations of our institutions concerning intellectual property. We further confirm that any aspect of the work covered in this manuscript that has involved human patients has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript. We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial Manager and direct communications with the office). He is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs.

A.D, S.R and C.F, designed research; A.D, S.R, E.I, M.B, A.P, A.M, G.T, C.M, A.Donato, L.IP, A.T, V.P, F.R, F.C and P.M conducted research; A.D, C.F, M.B and D.R. analysed data; and A.D, M.B. and C.F. wrote the paper. M.Benati and M.M performed laboratory analysis; C.F had primary responsibility for final content. All authors read and approved the final manuscript.