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Pulmonary Hypertension Rate 5.5% in Antiretroviral-Treated US Navy Group
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48th ICAAC, October 25-28, 2008, Washington, DC
Mark Mascolini
National Naval Medical Centers investigators reported a 5.5% prevalence of pulmonary arterial hypertension in 91 people with well-controlled HIV infection and no symptoms of pulmonary or cardiovascular disease [1]. The rate is much higher than that seen in people without HIV and slightly lower than in patients with symptomatic AIDS.
Because pulmonary hypertension is not easily diagnosed from symptoms, it tends to surface clinically in its later stages, when it can be life threatening [2]. A prospective cohort study of 7648 French people with HIV in the current treatment era charted a pulmonary hypertension prevalence of 0.46%, and most cases were mild [3]. However, in a German cross-sectional study of 802 HIV-infected people, pulmonary hypertension prevalence stood at 4.7% and affected women more than men (ratio 1.4 to 1) [4]. A retrospective study of 47 HIV-infected Swiss patients with pulmonary hypertension found that potent antiretroviral therapy improved the right ventricular systolic pressure over right atrial pressure gradient and significantly lowered the risk of death from pulmonary hypertension [5].
The Naval Medical Centers study involved 91 patients who underwent transthoracic echocardiography; 2 cardiologists unaware of patient clinical data interpreted the results. Defining pulmonary hypertension as pulmonary artery systolic pressure at or above 35 mmHg, the researchers assessed patients for correlations between pulmonary hypertension and HIV prognostic indicators, cumulative antiretroviral therapy, and cardiac risk factors.
The study group averaged 37 years in age (+/- 7), 10.8 years of HIV infection (+/- 6), 5.4 years of antiretroviral therapy (+/- 3.3), and a CD4 count of 583 (+/- 285). These measures did not differ much between the group with pulmonary hypertension and the nonhypertensive group. Median viral load measured 25 copies (interquartile range 25 to 2080) in people with pulmonary hypertension and 62 copies (interquartile range 25 to 1510) in people without pulmonary hypertension.
Five people met the study definition of pulmonary hypertension for a prevalence of 5.5% (95% confidence interval 1.81 to 12.36). All were men, 3 were white, and 2 were black. None reported injecting drugs. Median arterial pressure in these 5 men measured 36 mmHg (interquartile range, 36 to 37 mmHg), compared with a median of 23 mmHg (interquartile range 21 to 27) in the 86 people without pulmonary hypertension. Pulmonary artery pressure in the group with pulmonary hypertension did not differ significantly by protease inhibitor use, nadir CD4 count, AIDS risk score, or cardiovascular risk. Although 3 of 5 people with pulmonary hypertension had diastolic dysfunction, that indicator lacked statistical significance.
Pulmonary hypertension affects about 1 in 200,000 people in the general population, according to the Navy team. The rate in the Navy study is similar to that in the German study [4] and more than 10 times higher than the French study rate [3]. The US and German studies used the same definition of pulmonary hypertension. The French team diagnosed pulmonary hypertension if pulmonary arterial pressure at rest was 25 mmHg or greater (with pulmonary capillary wedge pressure at or below 15 mmHg) or 30 mmHg or greater on exercise.
References
1. Byers DK, Nayak G, Ferguson M, et al. Prevalence of pulmonary hypertension in
asymptomatic HIV-infected patients receiving antiretroviral therapy. 48th Annual International Conference on Antimicrobial Agents and Chemotherapy (ICAAC). October 25-28, 2008. Washington, DC. Abstract H-2312.
2. Opravil M, Sereni D. Natural history of HIV-associated pulmonary arterial hypertension: trends in the HAART era. AIDS. 2008;22(suppl 3):S35-S40.
3. Sitbon O, Lascoux-Combe C, Delfraissy JF, et al. Prevalence of HIV-related pulmonary arterial hypertension in the current antiretroviral therapy era. Am J Respir Crit Care Med. 2008;177:108-113.
4. Reinsch N, Buhr C, Krings P, et al. Effect of gender and highly active antiretroviral therapy on HIV-related pulmonary arterial hypertension: results of the HIV-HEART Study. HIV Med. 2008;9:550-556.
5. Zuber JP, Calmy A, Evison JM, et al. Pulmonary arterial hypertension related to HIV infection: improved hemodynamics and survival associated with antiretroviral therapy. Clin Infect Dis. 2004;38:1178-1185.
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