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

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.

Keywords: echocardiography; electronic health records; human immunodeficiency virus; patient outcome assessment; pulmonary hypertension.

Figure 1.

Adjusted risk of mortality according to pulmonary artery systolic pressure (PASP) value and HIV status. Restricted cubic spline plots of all-cause mortality according to PASP value and (A) HIV-infected, and (B) uninfected veterans. The reference group for HIV-infected individuals are HIV-infected subjects with a PASP value of 15 mm Hg and similar for uninfected individuals. There is a nonlinear relationship between PASP and mortality in HIV-infected veterans and higher risk at lower values compared with uninfected veterans. Adjusted for age, sex, race/ethnicity, hypertension, diabetes, dyslipidemia, hepatitis C virus infection, smoking status, renal disease, body mass index, anemia, alcohol dependence or abuse, chronic obstructive pulmonary disease, congestive heart failure, stroke, coronary heart disease, atrial fibrillation, and cancer. Values in brackets are 95% confidence intervals. HR = hazard ratio.

Figure 2.

Incremental change in adjusted risk by pulmonary artery systolic pressure (PASP) value. Point estimates and 95% confidence intervals represent the hazard ratios of death at each PASP comparing HIV-infected to uninfected veterans. Incremental risk is highest at lower values and remains higher in HIV-infected veterans at all values. This model includes PASP, HIV status, and the interaction between PASP and HIV status, along with adjustment for age, sex, race/ethnicity, hypertension, diabetes, low-density lipoprotein and high-density lipoprotein cholesterol, triglycerides, hepatitis C virus infection, smoking status, renal disease, body mass index, anemia, alcohol dependence or abuse, chronic obstructive pulmonary disease, congestive heart failure, stroke, coronary heart disease, atrial fibrillation, and cancer.