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HIV/AIDS
Original research
Risk of myocardial infarction among people living with HIV: an updated systematic review and meta-analysis
  1. Oghenowede Eyawo1,2,3,
  2. Gwenyth Brockman4,
  3. Charles H Goldsmith1,5,6,
  4. Mark W Hull3,
  5. Scott A Lear1,7,
  6. Matthew Bennett8,
  7. Silvia Guillemi3,
  8. Conrado Franco-Villalobos9,
  9. Ahmed Adam1,
  10. Edward J Mills6,
  11. Julio S G Montaner3,10,
  12. Robert S Hogg1,3
  1. 1 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  2. 2 Faculty of Health, York University, Toronto, ON, Canada
  3. 3 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
  4. 4 George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
  5. 5 Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Burnaby, British Columbia, Canada
  6. 6 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
  7. 7 Healthy Heart Program, St. Paul's Hospital, Providence Health Care, Vancouver, British Columbia, Canada
  8. 8 Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  9. 9 School of Public Health, University of Alberta, Edmonton, Alberta, Canada
  10. 10 Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Oghenowede Eyawo; oeyawo{at}yorku.ca

Abstract

Objective Cardiovascular disease (CVD) is one of the leading non-AIDS-defining causes of death among HIV-positive (HIV+) individuals. However, the evidence surrounding specific components of CVD risk remains inconclusive. We conducted a systematic review and meta-analysis to synthesise the available evidence and establish the risk of myocardial infarction (MI) among HIV+ compared with uninfected individuals. We also examined MI risk within subgroups of HIV+ individuals according to exposure to combination antiretroviral therapy (ART), ART class/regimen, CD4 cell count and plasma viral load (pVL) levels.

Design Systematic review and meta-analysis.

Data sources We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews until 18 July 2018. Furthermore, we scanned recent HIV conference abstracts (CROI, IAS/AIDS) and bibliographies of relevant articles.

Eligibility criteria Original studies published after December 1999 and reporting comparative data relating to the rate of MI among HIV+ individuals were included.

Data extraction and synthesis Two reviewers working in duplicate, independently extracted data. Data were pooled using random-effects meta-analysis and reported as relative risk (RR) with 95% CI.

Results Thirty-two of the 8130 identified records were included in the review. The pooled RR suggests that HIV+ individuals have a greater risk of MI compared with uninfected individuals (RR: 1.73; 95% CI 1.44 to 2.08). Depending on risk stratification, there was moderate variation according to ART uptake (RR, ART-treated=1.80; 95% CI 1.17 to 2.77; ART-untreated HIV+ individuals: 1.25; 95% CI 0.93 to 1.67, both relative to uninfected individuals). We found low CD4 count, high pVL and certain ART characteristics including cumulative ART exposure, any/cumulative use of protease inhibitors as a class, and exposure to specific ART drugs (eg, abacavir) to be importantly associated with a greater MI risk.

Conclusions Our results indicate that HIV infection, low CD4, high pVL, cumulative ART use in general including certain exposure to specific ART class/regimen are associated with increased risk of MI. The association with cumulative ART may be an index of the duration of HIV infection with its attendant inflammation, and not entirely the effect of cumulative exposure to ART per se.

PROSPERO registration number CRD42014012977.

  • Myocardial infarction
  • Cardiovascular disease
  • HIV
  • Combination antiretroviral therapy (ART)
  • Relative risk
  • Systematic review
  • Meta-analysis

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2018-025874

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    Footnotes

    • Contributors OE, MWH, SAL, JSGM and RSH conceived and designed the study. OE, GB and RSH acquired the data. OE performed the statistical analysis with input from CHG, CF-V and EJM. OE, GB, CHG, MWH, SAL, MB, SG, CF-V, AA, EJM, JSGM and RSH contributed to the interpretation of the data. OE drafted the manuscript. OE, GB, CHG, MWH, SAL, MB, SG, CF-V, AA, EJM, JSGM and RSH reviewed the manuscript critically for important intellectual content and approved the final version submitted for publication.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data and materials used in this research are available in Medline/PubMed. References have been provided.