What is the clinical evidence from this study?

Study design: Observational. Population: HIV infection and pulmonary hypertension (n=8296). Intervention: HIV infection with increased pulmonary artery systolic pressure (≥40 mm Hg) vs. HIV-uninfected with normal pulmonary artery systolic pressure (<40 mm Hg). Primary outcome: All-cause mortality (HR 1.78, 95% CI 1.57-2.01).

What does this research mean for the field?

HIV-infected individuals with a pulmonary artery systolic pressure ≥40 mm Hg have a significantly increased risk of death compared to uninfected individuals with normal pressure, and this mortality risk increases at lower PASP values than previously recognized. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

November 13, 2017

Increased Echocardiographic Pulmonary Pressure in HIV-infected and -uninfected Individuals in the Veterans Aging Cohort Study

Q: What are the key findings of this study?

HIV-infected veterans with a pulmonary artery systolic pressure ≥40 mm Hg had a significantly increased risk of death compared to uninfected veterans with normal pressure (HR 1.78).

Q: What does this research mean for the field?

HIV-infected individuals with a pulmonary artery systolic pressure ≥40 mm Hg have a significantly increased risk of death compared to uninfected individuals with normal pressure, and this mortality risk increases at lower PASP values than previously recognized. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Key Result

HIV-infected veterans with a pulmonary artery systolic pressure ≥40 mm Hg had a significantly increased risk of death compared to uninfected veterans with normal pressure (HR 1.78).

Study Design

Type

Observational (n=8,296)

Multicenter

Yes

Structured PICO

Does HIV infection and increased pulmonary artery systolic pressure increase mortality in veterans referred for echocardiography?

Population

8,296 veterans referred for echocardiography with reported pulmonary artery systolic pressure (PASP) estimates, including 2,831 HIV-infected and 5,465 HIV-uninfected veterans matched by age, sex, race/ethnicity, and clinical site.

Intervention

HIV infection and/or increased pulmonary artery systolic pressure (PASP ≥40 mm Hg)

Comparator

HIV-uninfected veterans and/or those with normal PASP (<40 mm Hg)

Outcome

Adjusted all-cause mortality by HIV status at mean 3.8 years follow-uphard clinical

HIV-infected veterans have a higher prevalence of increased pulmonary artery systolic pressure, which is associated with a significantly increased risk of mortality even at values currently considered normal.

Main Result

Effect estimate: HR 1.78 (95% CI 1.57-2.01)

Absolute Event Rate: 178% vs 54%

Limitations

Echocardiography referral population, limiting generalizability to the broader HIV community
PASP estimates were not collected according to a common protocol or interpreted by a central laboratory
Imperfect correlation between Doppler PASP estimates and invasive hemodynamics
Lack of data on right ventricular function
Lack of data on exposure to PAH-specific therapies
No access to data on self-reported substance use such as cocaine and methamphetamine
Unable to ascertain the indication for echocardiography
Relative paucity of women in the veteran population

Abstract

RATIONALE: The epidemiology and prognostic impact of increased pulmonary pressure among HIV-infected individuals in the antiretroviral therapy era is not well described. OBJECTIVES: To examine the prevalence, clinical features, and outcomes of increased echocardiographic pulmonary pressure in HIV-infected and -uninfected individuals. METHODS: This study evaluated 8,296 veterans referred for echocardiography with reported pulmonary artery systolic pressure (PASP) estimates from the Veterans Aging Cohort study, an observational cohort of HIV-infected and -uninfected veterans matched by age, sex, race/ethnicity, and clinical site. The primary outcome was adjusted mortality by HIV status. MEASUREMENTS AND MAIN RESULTS: PASP was reported in 2,831 HIV-infected and 5,465 HIV-uninfected veterans (follow-up mean ± SD, 3.8 ± 2.6 yr). As compared with uninfected veterans, HIV-infected veterans with HIV viral load greater than 500 copies/ml (odds ratio, 1.27; 95% confidence interval CI, 1.05-1.54) and those with CD4 cell count less than 200 cells/μl (odds ratio, 1.28; 95% CI, 1.02-1.60) had a higher prevalence of PASP greater than or equal to 40 mm Hg. As compared with uninfected veterans with a PASP less than 40 mm Hg, HIV-infected veterans with a PASP greater than or equal to 40 mm Hg had an increased risk of death (adjusted hazard ratio, 1.78; 95% CI, 1.57-2.01). This risk persisted even among participants without prevalent comorbidities (adjusted hazard ratio, 3.61; 95% CI, 2.17-6.01). The adjusted risk of mortality in HIV-infected veterans was higher at all PASP values than in uninfected veterans, including at values currently considered to be normal. CONCLUSIONS: HIV-infected people with high HIV viral loads or low CD4 cell counts have a higher prevalence of increased PASP than uninfected people. Mortality risk in HIV-infected veterans increases at lower values of PASP than previously recognized and is present even among those without prevalent comorbidities. These findings may inform clinical decision-making regarding screening and surveillance of pulmonary hypertension in HIV-infected individuals.

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