Risk of cardiovascular pathology determined using advanced cardiovascular imaging limited by heterogeneity amongst patients with human immunodeficiency virus

1. Prevalence of moderate coronary disease ranged from 0-52% amongst patients with human immunodeficiency virus (HIV) in this systematic review  as assessed using computed tomography.

2. Significant heterogeneity exists amongst studies of cardiovascular disease in patients with HIV precluding any definite conclusions about an association between the two.

Level of Evidence Rating: 1 (Excellent)

Study Rundown: Human immunodeficiency virus (HIV) has historically been a devastating illness and a significant cause of mortality. In light of novel antiretroviral therapies available in recent years, patients with HIV have been living longer lives. However, little is known about the systemic complications and chronic diseases associated with HIV later in life. The present study sought to systematically review and summarize the literature pertaining to cardiovascular disease in patients with HIV as assessed through advanced cardiac imaging techniques.

45 studies were reviewed in total, including 16 studies of computed tomography angiography (CTA), 16 of cardiac magnetic resonance imaging (CMR), 10 of positron emission tomography (PET) and three studies of more than one imaging modality. These studies reported on 5,218 patients with HIV and 2,414 healthy controls – these uninfected comparators were included in 30 studies. In total, 88% of patients with HIV were taking antiretroviral therapy. In the CT studies, the prevalence of moderate coronary stenosis ranged from 0-52% and severe coronary stenosis ranged from 0-32%. In the CMR studies, the prevalence of late gadolinium enhancement ranged from 5-84%, and in the PET studies there was no conclusive evidence that HIV was associated with greater cardiac inflammation than healthy controls. There was a moderate to large amount of heterogeneity amongst each set of comparable studies.

This systematic review & meta-analysis sought to determine whether HIV increases the risk of cardiovascular disease. However, the group of included studies was plagued with considerable heterogeneity which precluded this meta-analysis from definitively supporting the notion that cardiovascular risk is increased amongst patients with HIV. The many subgroup analyses performed were unable to overcome this heterogeneity to form meaningful conclusions about the prevalence or risks of cardiovascular disease in this population. As advanced cardiac imaging techniques become more accessible, future prospective study to determine the true prevalence of disease amongst patients with HIV should be conducted.

Click here to read this study in JAMA

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Relevant reading: HIV infection and cardiovascular disease

In Depth [systematic review & meta-analysis]: A systematic review and meta-analysis of the literature was conducted using the following databases: Medline, Embase, Google Scholar and Global Health. Studies of advanced cardiac imaging techniques amongst adult patients with HIV published from database inception until February 11, 2022, were included. A hand search of relevant references was also performed. Eligible forms of advanced cardiac imaging included: CTA, CMR and vascular or cardiac PET. The National Heart, Lung, and Blood Institute quality assessment tool for observational and cohort studies was used to assess risk of bias amongst included studies.

3891 studies were mined from the literature search and of these, 45 were eligible for inclusion. Most studies were conducted in high-income countries (78%) and the most common study design was cross sectional (85%). Nearly half (47%) of the included studies had a moderate risk of bias, whereas 31% had high and 22% had low risk of bias.

In the CT studies, the prevalence of moderate coronary stenosis ranged from 0-52% and severe coronary stenosis ranged from 0-32%. These estimates were generated from 15 studies including 2541 patients. There was moderate heterogeneity amongst this sample (I² =62%). In 11 studies, patients with HIV were compared with healthy controls and the prevalence of coronary disease ranged from 0-52% (moderate) and 0-27% (severe). The prevalence ratio for association of HIV and moderate/severe coronary disease ranged from 0.33 to 5.19.

In the CMR studies, the prevalence of late gadolinium enhancement ranged from 5-84%. These estimates were generated from 15 studies including 1180 patients. There was considerable heterogeneity amongst this sample (I² =88%). In 9 studies, patients with HIV were compared with healthy controls and the prevalence of late gadolinium enhancement ranged from 0-68%. The prevalence ratio for association of HIV and cardiac disease on CMR ranged from 1.01 to 17.35. Finally, in the PET studies, the difference in vascular inflammation as measured by fluorinated tracers between patients with HIV and healthy controls ranged from 0.06 (95% confidence interval 0.01-0.11) to 0.37 (0.02-0.72). There was moderate heterogeneity amongst this sample (I² =64%).

Image: PD

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