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Tissue Doppler Imaging on Transthoracic ECHO to Assess Prevalence of HIV-Associated Pulmonary Hypertension

Naru Singh

Sejal Shah

V Ly

Hector Ojeda-Martinez

Mohammad Al-Ajam

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Conference: 2018 PHA International PH Conference & Scientific Sessions

Release Date: 06.28.2018

Presentation Type: Abstracts

File Download: Conference 2018_1040

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2018 International PH Conference and Scientific SeAbstract presented at the 2018 International PH Conference and Scientific Sessions in Orlando, Fla., June 28-July 1, 2018.

Background

Pulmonary Hypertension is classified based on etiology, with human immunodeficiency virus (HIV) associated disease falling into Group 1 Pulmonary Arterial Hypertension (PAH). The mortality of PAH is several folds higher in patients with HIV than without, reaching 40% for patients in World Health Organization Functional Class (WHO-FC) III-IV. Despite this poor prognosis, no evidence exists to support routine screening for HIV-associated PAH in high-risk populations. While transthoracic echocardiography (ECHO) has not shown ideal correlation with findings on right heart catheterization, use of ECHO is still a well-accepted noninvasive screening tool to assess for possible PAH. Several studies have used transthoracic echocardiogram (ECHO) to look at the prevalence of PAH in the HIV population with some studies estimating prevalence between 0.5 and 2%, however this has only been investigated in symptomatic patients. By using advanced but widely available echocardiographic techniques such as tissue doppler imaging (TDI), the accuracy of ECHO as a screening tool may improve. The purpose of this study was to further understand the clinical utility of screening asymptomatic HIV-positive patients for PAH. Given the reported poor survival in this population, identifying asymptomatic patients with PAH would allow for earlier surveillance and intervention.

Methods

This was a retrospective review of HIV-infected patients at the Brooklyn VA. All HIV-positive patients seen in the HIV clinic between January 2015 to September 2016 were chart-reviewed and assessed for prevalence of pulmonary arterial systolic pressure (PASP) greater than 35mmHg as assessed by transthoracic ECHO to be suggestive of PAH. Those ECHOs with noted PAH were reassessed using Tissue Doppler Imaging (TDI) to estimate the pulmonary capillary wedge pressure (PCWP) via the mitral valve regurgitant velocity. Other variables such as age, gender, CD4 count, viral load, anti-retroviral therapy and cardiopulmonary comorbidities were also collected.

Results

Of 100 HIV-positive patients who received a transthoracic ECHO from January 2015 to September 2016, 3 ECHOs were not done using TDI and 1 was done on a patient not in sinus rhythm. Of the remaining 96 patients, 15 had a PAH > 35mmHg with a PCWP less than 15mmHg. This suggests a prevalence of PAH of 15.6% (95% CI 9%-24%) in this population. Out of these patients, only 13.3% were noted to have uncontrolled viral load, the remainder had suppressed viral loads and absolute CD4 >200.

Conclusions

There is a higher prevalence of PAH found amongst the HIV-positive population at our institution than would be expected based on prior data. Given the elevated mortality of this disease, we propose that all HIV-positive patients should be screened with transthoracic ECHO for elevations in their PASP. TDI estimations of PCWP should be included in this screening to improve the sensitivity of this screening test. This information should be used to pursue guideline-directed diagnostic workup both at the time of screening and as symptoms develop.