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Late Catheterization and Significant Coronary Artery Disease in US HIV Group
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52nd ICAAC, September 9-12, 2012, San Francisco
Mark Mascolini
HIV-positive people undergoing cardiac catheterization often already had unstable angina or myocardial infarction (MI), according to results of a case-control comparison of people seen at HIV clinics at Duke University and the University of North Carolina (UNC) at Chapel Hill [1]. Almost two thirds of HIV-positive people in this study had significant coronary artery disease (CAD) when they had catheterization.
"Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. Subsets of this technique are mainly coronary catheterization, involving the catheterization of the coronary arteries, and catheterization of cardiac chambers and valves."
Delayed catheterization poses a threat of worsening cardiac morbidity and significant CAD. No studies of cardiac catheterization in HIV-positive people appear in the literature. Researchers at two southeastern US institutions with large HIV clinics undertook this study to compare clinical features of HIV-positive and negative people undergoing their first catheterization for chest pain or suspected coronary artery disease. HIV-positive cases and HIV-negative controls were eligible for the study if they had a primary care provider before onset of symptoms leading to catheterization, had at least 3 visits before catheterization, and had their most recent visit in the previous 3 years. No one had a diagnosis of CAD at the time of catheterization.
The study involved 96 HIV-positive people who had their first cardiac catheterization for chest pain or suspected CAD from January 1996 through March 2010. The Duke/UNC team matched them by gender, age, and socioeconomic status to 41 HIV-negative people who also had their first catheterization for the same reasons. Patients in the comparison group were seen at an internal medicine clinic for underserved people. The researchers noted that finding age-matched HIV-negative controls was "very difficult." They defined significant CAD as at least 50% stenosis of at least one major vessel.
[stenoses is an abnormal narrowing in a blood vessel or other tubular organ or structure.]
Median age was only 49 in the HIV-positive group (interquartile range [IQR] 44 to 53) and--because of matching--50 in the HIV-negative group (IQR 47 to 52). A slightly higher proportion of the HIV group was male (75% versus 59%, P = 0.07), and similar proportions were African American (65% with HIV and 71% without HIV, P = 0.56).
HIV-positive people tended to smoke more than HIV-negative people (51% versus 37%, P = 0.14), but rates of cocaine use were similar in the two groups (17% and 10%, P = 0.43). A significantly higher proportion of HIV-positive people had end-stage renal disease (15% versus 0, P = 0.01), and a significantly lower proportion had diabetes (23% versus 42%, P = 0.04). Rates of hypertension, hyperlipidemia, and other cardiovascular risk factors were similar between the two groups. Most HIV-positive people (87%) were on antiretroviral therapy.
Among the 96 people with HIV, 52 (54%) had their cardiac catheterization for unstable angina or MI. In contrast, only 14 HIV-negative people (34%) had their procedures for those reasons, a significant difference (P = 0.04). Catheterization showed significant CAD in 60 people with HIV (63%) and 22 without HIV (54%) (P = 0.35). Similar proportions of people with and without HIV had medical management of their condition (30% and 32%), percutaneous coronary intervention (52% and 46%), or coronary artery bypass grafting (18% and 23%).
The researchers concluded that "significant CAD was very common in HIV+ patients going for catheterization (63%) despite the young median age of 49 years." They believe the high proportion of catheterizations for MI or unstable angina in the HIV group "suggests health care providers may not consider CAD early enough in younger HIV+ patients."
The investigators surmised that providers may not routinely evaluate cardiac risk factors or angina symptoms in HIV-positive people. They suggested "having a primary care provider in addition to an HIV care provider may be a worthwhile approach" or that HIV providers need better education to improve their awareness of CAD and its management.
Reference
1. Kaiser C, Chin T, Napravnik S, et al. Early onset and late diagnosis of CAD in HIV+ persons. 52nd Interscience Conference on Antimicrobials and Chemotherapy (ICAAC). September 9-12, 2012. San Francisco. Abstract H-229.
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