Proteomic signature of HIV-associated subclinical left atrial remodeling and incident heart failure

Abstract

People living with HIV are at higher risk of heart failure and associated left atrial remodeling compared to people without HIV. Mechanisms are unclear but have been linked to inflammation and premature aging. Here we obtain plasma proteomics concurrently with cardiac magnetic resonance imaging in two independent study populations to identify parallels between HIV-related and aging-related immune dysfunction that could contribute to atrial remodeling and clinical heart failure. We discover a plasma proteomic signature that may in part reflect or contribute to HIV-associated atrial remodeling, many features of which are associated with older age and time to incident heart failure among an independent community-based cohort without HIV. This proteomic profile was statistically enriched for immune checkpoint proteins, tumor necrosis factor signaling, ephrin signaling, and extracellular matrix organization, identifying possible shared pathways in HIV and aging that may contribute to risk of heart failure.

Fig. 1. Graphical representation of the study design and analytic flow.

Cross-sectional discovery analyses were performed in the Subclinical Myocardial Abnormalities in HIV Study (SMASH) using linear regression with robust variance. Analyses of HIV serostatus adjusted for sociodemographics, substance use, hepatitis C virus infection, and renal function. Analyses of left atrial size further adjusted for HIV serostatus, body mass index, systolic blood pressure, hypertension medication use, dyslipidemia, and diabetes. Both cross-sectional and longitudinal time-to-incident event analyses were performed among an external population of older people without HIV in the Multi-Ethnic Study of Atherosclerosis (MESA). Cross-sectional analyses of left atrial size were performed using linear regression with robust variance, adjusting for field center, sociodemographics, smoking, body mass index, systolic blood pressure, hypertension medication use, dyslipidemia, diabetes, and renal function. Time-to-event analyses of atrial fibrillation and heart failure were performed using Cox proportional hazards regression, adjusting for the same covariates. Proteome feature counts listed are those associated with indicated outcomes at a false discovery rate < 0.05.

Fig. 2. Proteomic signature of HIV seropositivity among people living with and without HIV in the United States (n = 352).

a Volcano plot of mean differences in standardized plasma protein abundance comparing PLWH to PWOH vs. -log₁₀ false discovery rate (FDR; Benjamini-Hochberg) estimated using linear regression with robust variance, adjusting for sociodemographics, substance use, hepatitis C virus infection, and renal function. The threshold for significance is indicated by a gray dotted line, FDR < 0.05; 415 of 2596 proteins were positively associated with positive HIV serostatus and 24 proteins were inversely associated; comparing suppressed PLWH vs. PWOH, 414 of these 439 total proteins were associated with suppressed positive HIV serostatus (not depicted). Complete modeling results can be found in Supplementary Data 1. b Enriched biological processes among proteins associated with HIV serostatus, estimated using a two-sided Fisher’s exact test, Gene Ontology: Biological Processes annotations, and a threshold for significance of FDR < 0.05. Protein ratio = proportion of proteins significantly associated with HIV serostatus (n = 439) that map to the given annotation. Proteins mapping to each annotation can be found in Supplementary Table S3. PLWH = persons living with HIV; PWOH = persons without HIV; suppressed HIV viral load = HIV RNA < 50 copies/µL.

Fig. 3. HIV-associated proteomic signature of left atrial size among people living with and without HIV in the United States (n = 352).

a Volcano plot of mean differences in left atrial volume index (LAVi) per standard deviation (SD) increment in plasma abundance of 439 HIV-associated proteins vs. -log₁₀ false discovery rate (FDR; Benjamini-Hochberg) estimated using linear regression with robust variance. Purple indicates proteins only associated in Model 1 (M1) when adjusting for sociodemographics, HIV, hepatitis C virus (HCV) infection, and renal function. Orange indicates proteins associated in Model 2 (M2) following further adjustment for education, cardiovascular risk factors, and substance use. The threshold for significance is indicated by a gray dotted line, FDR < 0.05. The most saturated model (orange) yielded 69 proteins positively associated with LAVi and 4 proteins inversely associated. Complete modeling results can be found in Supplementary Data 3. b Beta-beta plot of mean differences in standardized protein abundances comparing persons living with vs. without HIV (PLWH, PWOH) vs. mean differences in LAVi per SD increment in plasma protein abundances. All associations were estimated using linear regression with robust variance, and proteins depicted (n = 73) are restricted to those significantly associated with both parameters with an FDR < 0.05. HIV point estimates (y-axis) were adjusted for sociodemographics, substance use, HCV, and renal function. LAVi point estimates (x-axis) were adjusted for the same covariates, plus HIV and cardiovascular risk factors. c Enriched biological processes among proteins associated with both positive HIV serostatus and higher LAVi (concordant directionality), estimated using a two-sided Fisher’s exact test, Gene Ontology: Biological Processes annotations, and a threshold for significance of FDR < 0.05. Protein ratio = proportion of total signature proteins (n = 73) that map to the given annotation. TNF = tumor necrosis factor; NK = natural killer; PDGF = platelet-derived growth factor. Proteins mapping to each annotation can be found in Supplementary Table S7. d Mean differences in LAVi per SD increment in plasma protein abundances among strata of PLWH and PWOH, estimated using linear regression with robust variance adjusting for sociodemographics, substance use, cardiovascular risk factors, HCV, and renal function. Proteins depicted are limited to those with HIV×protein multiplicative interactions with an FDR < 0.10 (n = 73 proteins tested). Error bars indicate 95% confidence intervals.

Fig. 4. Relationship between an HIV-associated, agnostically defined cluster of plasma proteins and left atrial size among people living with and without HIV in the United States (n = 352).

a Mean difference in indexed left atrial volume (LAVi) per standard deviation (SD) increment in ‘Brown’ protein cluster plasma abundance among all participants, among strata of participants living with and without HIV, and among strata of participants above and below median age in SMASH (55 years), estimated using linear regression with robust variance adjusting for sociodemographics, substance use, cardiovascular risk factors, hepatitis C virus infection, and renal function. Error bars indicate 95% confidence intervals. b Enriched biological processes among 42 proteins comprising the ‘Brown’ protein cluster, estimated using a two-sided Fisher’s exact test, Gene Ontology: Biological Processes annotations, and a threshold for significance of Benjamini-Hochberg false discovery rate (FDR) < 0.05. Protein ratio=proportion of total ‘Brown’ cluster proteins (n = 42) that map to the given annotation. Proteins mapping to each annotation can be found in Supplementary Table S6. c Interaction network of 42 proteins comprising the ‘Brown’ protein cluster generated using STRING, a public database of known and predicted protein-protein interactions. Interactions include direct (physical) and indirect (functional) associations derived from computational prediction, knowledge transfer between organisms, and interactions aggregated from other databases. Line thickness indicates the strength of data support. Szklarczyk D, et al. The STRING database in 2023: protein-protein association networks and functional enrichment analyses for any sequenced genome of interest. Nucleic Acids Res. 2023;51(D1):D638-64.

Fig. 5. Associations between identified HIV-associated proteomic signature of left atrial size and time to incident adjudicated clinical heart failure in the Multi-Ethnic Study of Atherosclerosis (n = 2273).

Hazard ratios were estimated using Cox proportional hazards adjusting for study site, age, sex, race, ethnicity, educational attainment, body mass index, systolic blood pressure, anti-hypertensive medication, dyslipidemia, diabetes, smoking, and estimated glomerular filtration rate. N = 54 incident adjudicated heart failure events. Purple indicates p < 0.05, Orange indicates FDR < 0.05. Complete modeling results can be found in Supplementary Table S14, and source data are provided as a Source Data file. SD = standard deviation; FDR = alse discovery rate (Benjamini-Hochberg).