Symptomatic HIV Patients with ACS Undergo Fewer Revascularization Procedures

Meredith E. Clement, MD, lead study author and Infectious Disease Fellow at the Duke University Medical Center

Meredith E. Clement, MD

Symptomatic HIV patients with concomitant acute coronary syndrome (ACS) undergo fewer cardiovascular interventions (eg, percutaneous coronary intervention [PCI] or coronary bypass grafting [CABG]) compared with asymptomatic HIV patients and the general uninfected population, according to new study findings from Duke University researchers.¹

"We looked at a large claims database of hospitalizations for ACS and found that patients with symptomatic AIDS were less likely to receive cardiac revascularization procedures relative to uninfected persons,” according to lead study author Meredith E. Clement, MD, Infectious Disease Fellow, Duke University Medical Center, “while those with asymptomatic HIV were not less likely to receive these procedures."

Using data from the National Inpatient Sample (NIS), investigators evaluated asymptomatic HIV-infected patients, symptomatic acquired immunodeficiency syndrome (AIDS) patients, and generally healthy uninfected patients (n = 1,093,849). All patients were admitted to the hospital with ACS, including ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina (UA), between the years of 2009—2012. Investigators assessed the rates of catheterization/revascularization as well as time to treatment.

Of the NIS sample, a total of 3792 (0.35%) were HIV positive. Compared with uninfected and asymptomatic AIDS patients, those with symptomatic HIV/AIDS patients had higher rates of kidney disease, malignancy and liver disease upon admission. In addition, alcohol and substance abuse, as well as smoking, were higher among those infected with HIV versus the general population.

Revascularization with PCI or CABG was 37.4% for the entire sample. In the crude analysis, patients with symptomatic HIV/AIDS had lower rates of revascularization than those with symptomatic HIV infection or uninfected patients (28.4% vs. 43.5% and 37.4%, respectively). The adjusted, multivariable analysis demonstrated that patients with symptomatic HIV/AIDS had a significantly lower chance of undergoing PCI (OR 0.69, CI 0.59—0.79) and CABG (0.75, CI 0.61–0.93) vs. asymptomatic HIV patients (PCI: OR 1.06, CI 0.93–1.21 and CABG: OR 0.88, CI 0.72–1.06).

A lower proportion of patients with symptomatic HIV/AIDS received a drug-eluting stent (DES) compared with asymptomatic and uninfected patients (60.1% vs 66.8% and 73.0%, respectively). Following adjustment for multiple variables, the investigators found that both asymptomatic (OR 0.78, CI 0.63—0.95) and symptomatic (0.68, CI 0.50–0.93) HIV/AIDS patients had a lower likelihood of receiving a DES compared with uninfected patients.

Additionally, the hospital length of stay was longer among symptomatic HIV/AIDS vs those with asymptomatic HIV and uninfected patients (mean 8.3 days vs 4.5 days and 5.5 days, respectively). In-hospital mortality rates were also higher among those with symptomatic HIV/AIDS compared with uninfected patients (OR 2.23, CI 1.85—2.69).

"It is clear that in some disease states, such as cancer, treatment disparities exist with respect to HIV status. Practitioners should try to ensure they are providing standard of care procedures when appropriate, and work to eliminate health disparities when they are shown to exist,” added Clement. “However, our findings offer some reassurance that provider bias in the setting of cardiac disease is not as prominent as previously thought, given that those with asymptomatic HIV infection were no less likely to receive care."

REFERENCE

1. Clement ME, Lin L, Navar AM, et al. Lower likelihood of cardiac procedures after acute coronary syndrome in patients with human immunodeficiency virus/acquired immunodeficiency syndrome. Medicine (Baltimore). 2018;97(6):e9849.