Risk of cardiovascular disease determined using advanced cardiovascular imaging limited by heterogeneity among patients with human immunodeficiency virus

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1. The prevalence of moderate coronary artery disease ranged from 0 to 52% in human immunodeficiency virus (HIV) patients in this systematic review, as assessed using computed tomography.

2. Significant heterogeneity exists among studies of cardiovascular disease in HIV-positive patients, precluding any firm conclusion on an association between the two.

Assessment of the level of proof: 1 (Excellent)

Summary of the study: The human immunodeficiency virus (HIV) has always been a devastating disease and a major cause of death. In light of the new antiretroviral therapies available in recent years, HIV-positive patients are living longer. However, little is known about the systemic complications and chronic illnesses associated with HIV later in life. The present study aimed to systematically review and summarize the literature related to cardiovascular disease in HIV-infected patients assessed using advanced cardiac imaging techniques.

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

This systematic review and meta-analysis aimed to determine whether HIV increases the risk of cardiovascular disease. However, the pool of included studies was plagued by considerable heterogeneity which prevented this meta-analysis from conclusively supporting the idea that cardiovascular risk is increased in HIV patients. The numerous subgroup analyzes performed did not overcome this heterogeneity to draw meaningful conclusions about the prevalence or risk of cardiovascular disease in this population. As advanced cardiac imaging techniques become more accessible, a future prospective study aimed at determining the true prevalence of the disease in HIV-positive patients should be conducted.

Click here to read this study in JAMA

Click to read an accompanying editorial in JAMA

Relevant reading: HIV infection and cardiovascular disease

In depth [systematic review & meta-analysis]: A systematic review and meta-analysis of the literature was performed using the following databases: Medline, Embase, Google Scholar and Global Health. Studies of advanced cardiac imaging techniques in adult HIV patients published from the inception of the database up to February 11, 2022 were included. A manual 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’s Quality Assessment Tool for Observational and Cohort Studies was used to assess risk of bias among included studies.

3891 studies were retrieved 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%). Almost half (47%) of the included studies were at moderate risk of bias, while 31% were at high risk and 22% at low risk of bias.

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

In CMR studies, the prevalence of late gadolinium enhancement ranged from 5 to 84%. These estimates were generated from 15 studies including 1180 patients. There was considerable heterogeneity among this sample (I2 =88%). In 9 studies, HIV-positive patients were compared with healthy controls and the prevalence of late gadolinium enhancement ranged from 0 to 68%. The prevalence ratio for the association of HIV and heart disease on CMR ranged from 1.01 to 17.35. Finally, in PET studies, the difference in vascular inflammation measured by fluoride tracers between HIV-positive patients 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 among this sample (I2 =64%).

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