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Original Investigation
September 13, 2022

Association of HIV Infection With Cardiovascular Pathology Based on Advanced Cardiovascular Imaging: A Systematic Review

Author Affiliations
  • 1Kings College London British Heart Foundation Centre, School of Cardiovascular and Metabolic Medicine & Sciences, London, United Kingdom
  • 2Department of Cardiology, Epsom and St Helier University Hospitals Trust, London, United Kingdom
  • 3Biomedical Research and Training Institute, Harare, Zimbabwe
  • 4Department of Medical Physics and Imaging Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe
  • 5Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
  • 6Department of Non-communicable Disease, London School of Hygiene & Tropical Medicine, London, United Kingdom
  • 7Department of Cardiology, North Bristol NHS Trust, Bristol, London, United Kingdom
  • 8Department of Cardiology, Imperial College NHS Trust, London, United Kingdom
JAMA. 2022;328(10):951-962. doi:10.1001/jama.2022.15078
Key Points

Question  What is the association between HIV infection and cardiovascular pathology based on advanced cardiovascular imaging?

Findings  This systematic review included 45 studies (5218 persons living with HIV and 2414 persons without infection) predominantly from high-income countries. Prevalence ranges among persons living with HIV were 0% to 52% for moderate to severe coronary disease and 5% to 84% for myocardial fibrosis. Estimates of the associations between HIV and cardiovascular pathologies demonstrated large amounts of heterogeneity.

Meaning  This systematic review provides a summary of the available data about imaging-based cardiovascular pathologies among persons living with HIV, although interpretation is limited by the large amount of heterogeneity and lack of data from low-income countries with higher HIV endemicity.

Abstract

Importance  HIV-associated cardiovascular disease is increasing in prevalence, but its mechanisms remain poorly understood.

Objective  To systematically review data from advanced cardiovascular imaging studies evaluating computed tomographic coronary angiography, positron emission tomography (PET), and cardiac magnetic resonance (MR), in people living with HIV compared with uninfected individuals.

Data Sources  Three databases and Google Scholar were searched for studies assessing cardiovascular pathology using computed tomographic coronary angiography, cardiac MR, PET, and HIV from inception to February 11, 2022.

Study Selection  Two reviewers selected original studies without any restrictions on design, date, or language, investigating HIV and cardiovascular pathology.

Data Extraction and Synthesis  One investigator extracted data checked by a second investigator. Prevalence ratios (PRs) and differences in inflammation among people living with HIV and uninfected individuals were qualitatively synthesized in terms of cardiovascular pathology. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for observational studies.

Main Outcomes and Measures  Primary outcomes were computed tomographic coronary angiography–defined moderate to severe (≥50%) coronary stenosis, cardiac MR–defined myocardial fibrosis identified by late gadolinium enhancement, and PET-defined vascular and myocardial target to background ratio. Prevalence of moderate to severe coronary disease, as well as myocardial fibrosis, and PRs compared with uninfected individuals were reported alongside difference in vascular target to background ratio.

Results  Forty-five studies including 5218 people living with HIV (mean age, 48.5 years) and 2414 uninfected individuals (mean age, 49.1 years) were identified. Sixteen studies (n = 5107 participants) evaluated computed tomographic coronary angiography; 16 (n = 1698), cardiac MRs; 10 (n = 681), vascular PET scans; and 3 (n = 146), both computed tomographic coronary angiography and vascular PET scans. No studies originated from low-income countries. Regarding risk of bias, 22% were classified as low; 47% moderate; and 31% high. Prevalence of moderate to severe coronary disease among those with vs without HIV ranged from 0% to 52% and 0% to 27%, respectively, with PRs ranging from 0.33 (95% CI, 0.01-15.90) to 5.19 (95% CI, 1.26-21.42). Prevalence of myocardial fibrosis among those with vs without HIV ranged from 5% to 84% and 0% to 68%, respectively, with PRs ranging from 1.01 (95% CI, 0.85-1.21) to 17.35 (95% CI, 1.10-274.28). Differences in vascular target to background ratio among those with vs without HIV ranged from 0.06 (95% CI, 0.01-0.11) to 0.37 (95% CI, 0.02-0.72).

Conclusions and Relevance  In this systematic review of studies of advanced cardiovascular imaging, the estimates of the associations between HIV and cardiovascular pathologies demonstrated large amounts of heterogeneity. The findings provide a summary of the available data but may not be representative of all individuals living with HIV, including those from low-income countries with higher HIV endemicity.

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