American study finds promising results when people with HIV undergo coronary bypass surgery

• People with HIV are at increased risk for heart disease, including heart attack and stroke
• Coronary bypass surgery outcomes were compared in 613 people with and 3,119 without HIV
• Researchers found similar rates of death (2%) in people from both groups

People with HIV are at heightened risk for cardiovascular disease—heart attack, stroke and the need for cardiovascular surgery. These issues arise because over the long-term HIV infection is associated with an increased risk for chronic inflammation and excess activation of the immune system. 

When used as directed, HIV treatment (antiretroviral therapy, ART) helps suppress the amount of HIV in the blood. This viral suppression helps to reduce levels of HIV-related inflammation and immune activation. However, these issues are not completely resolved with ART. 

Additional cardiovascular risk arises in some people with HIV from aging-related conditions such as high blood pressure, pre-diabetes and diabetes, and excess weight. Tobacco smoking and drug use also contribute to poor cardiovascular health.

It is possible that the use of older HIV drugs (no longer recommended by leading treatment guidelines) have also contributed to cardiovascular disease risk.

One or more of these risk factors can intensify the deposition of fatty substances (plaque) in people’s arteries. Over time, as more plaque gets deposited in arteries, the arteries can carry less oxygen-rich blood to the heart. Plaque is sticky and can attract debris, which increases the risk for the formation of unnecessary blood clots to form. Large clots can block the flow of blood.

As the heart is an active muscle that constantly pumps blood, when it receives less oxygen it can become injured and less efficient. Ultimately, this can cause the heart to malfunction and stop working.

Bypass surgery

In cases of clogged arteries, surgeons can perform coronary artery bypass surgery. For this surgery they remove a blood vessel from the leg, chest or arm and place it onto the affected artery, connecting the unclogged parts of the artery. This allows blood to resume flowing to the heart. Some people require two or more grafts of blood vessels, depending on the severity of their arterial disease. 

Coronary bypass surgery saves lives but does not address the underlying cause(s) of heart disease. Patients with coronary artery disease will need to engage in doctor-approved regular exercise and, if necessary, changes to their diet (resulting in weight reduction) and smoking cessation. In addition, it may be necessary to take medicines to help reduce cholesterol levels and the risk for unnecessary blood clot formation. 

In the U.S.

A team of researchers at George Washington University School of Medicine and Health Sciences in Washington, D.C., analysed health-related information stored in a large database. Their analysis explored trends associated with coronary bypass surgery.

The researchers assessed data from 613 people with HIV and 3,119 people without HIV who were demographically similar. They found that in-hospital death rates after coronary bypass surgery were similar—about 2%—in both groups of people. 

Among people with HIV, issues that increased their risk for death included the following:

• previous coronary bypass surgery
• chronic lung disease
• narrowing of the blood vessels in the feet or legs (peripheral artery disease)
• severe kidney injury 

Further details appear later in this CATIE News bulletin.

Study details

Researchers used anonymized data from the U.S. National Inpatient Sample (NIS). This database provides information on about 20% of hospitalizations in the United States. 

Researchers considered non-surgical issues, including the following:

• sex
• age
• race/ethnicity
• health insurance status
• health conditions

No information on HIV-related issues (such as CD4+ cell count, viral load or type of ART used) was available.

The researchers also considered hospital-related issues where surgery took place. Such issues included the size of the hospital (total number of beds), geographic location, teaching status and so on.

The researchers examined outcomes that occurred in the hospital, such as complications affecting the heart, brain, kidneys, lungs and so on.

They assessed data between the years 2015 and 2020. During that time, 613 patients (0.36%) who underwent coronary artery bypass had HIV. Each of these people was matched with at least five demographically similar people without HIV (3,119 in total) who also underwent coronary artery bypass during the same period.

Among people with HIV, 87% were male and 13% were female.

Results

People with HIV were more likely to:

• be male
• be younger than 65 years
• be a person of colour
• have a low income
• receive government-subsidized healthcare
• enter the hospital via the emergency department

The researchers also found that people with HIV were more likely to have the following issues:

• depression (17% vs. 9% of people without HIV)
• substance use disorder (7% vs. 2% of people without HIV)
• complicated high blood pressure (46% vs. 36%)
• severe kidney disease (6% vs. 2%)
• anemia (8% vs. 4%)
• previous heart attack (24% vs. 18%)

However, by matching people who were socially, medically and demographically similar, researchers were able to minimize these differences when analyzing outcomes.

In-hospital outcomes

After matching populations (HIV and non-HIV) researchers found similar rates of death (2%) among people in both groups.

However, the researchers did find that people with HIV who underwent coronary artery bypass were more likely to experience the following:

• acute kidney injury (27% vs. 22% of people without HIV)
• infection (8% vs. 4% of people without HIV)

As mentioned earlier, people with HIV who had one or more of the following factors were at increased risk of death:

• previous coronary bypass surgery
• chronic lung disease
• narrowing of the blood vessels in the feet or legs (peripheral artery disease)
• severe kidney injury 

Another large U.S. study has also found an increased risk of infection (pneumonia) after coronary bypass surgery in people with HIV.

For the future

The present analysis should be seen as an overview of the outcome of coronary bypass surgery in people with HIV. In general, such surgery holds very promising results for people with HIV. On its own, HIV infection should not be used as a reason to withhold access to this lifesaving surgery. Individual circumstances may vary, and the researchers were unable to access information about specific cardiovascular issues, as these were not in the database. 

As mentioned earlier, there was no information about CD4+ cell counts, viral load or type of HIV treatment. 

The NIS database does not have records about what happened to people after they left the hospital. Therefore, the long-term prospects of people with HIV who underwent coronary bypass surgery in this study are not known.

—Sean R. Hosein

Resources

Cholesterol-lowering medicine found beneficial for people with HIV who are at low-to-moderate risk of cardiovascular disease – CATIE News

HIV and cardiovascular disease – CATIE

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