PCI Efficacy Unaffected by HIV Status

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Patients with human immunodeficiency virus (HIV) and coronary artery disease (CAD) who undergo percutaneous coronary intervention (PCI) have procedural success and outcomes comparable to those without the virus and therefore should not be precluded from intervention, according to a study published online June 17, 2014, ahead of print in Catheterization and Cardiovascular Interventions. Moreover, use of DES appears safe in these patients and is recommended as more effective than implantation of bare-metal stents (BMS).

Similar Angiographic Success, TVR-MACE

Angiographic success was 98.8%, and DES use was 72% in both groups. At 2 years, clinical restenosis was not different between HIV-positive and HIV-negative patients (15.4% vs 9.9%; P = .29).

Additionally, there was no difference in the primary endpoint over the entire follow-up period (table 1).

Table 1. Outcomes over Time by HIV Status^a

^aP = NS for all.   

There was no correlation between CD4 nadir count, an index of viral load, in HIV-positive patients and the extent of diffuseness of CAD.

Multivariate analysis determined independent predictors of the primary endpoint to be acute MI at initial diagnosis (HR 2.92; 95% CI 1.39-6.15; P = .005) and a history of chronic renal insufficiency (HR 2.44; 95% CI 1.02-5.83; P = .044). HIV status was not a predictor.

Post-hoc analysis also found that patients who received DES vs BMS tended to have lower rates of TVR-MACE regardless of HIV status.

Reassurance Regarding Safety

 The authors say that the study has several important findings including:

• The spectrum of coronary heart disease is similar in patients with and without HIV
• PCI is effective and safe in HIV-positive patients without an increase in adverse events
• Treatment with a DES is safe and encouraged in HIV-positive patients

“One of the things people are concerned about is that DES is associated with more stent thrombosis that requires more antiplatelet therapy or longer duration,” Dr. Waksman told TCTMD in a telephone interview. “The study gives some assurances that DES [are] safe…. With respect to patients who are HIV-positive, our recommendation is that they should get DES because they are performing in general better than BMS and there are no issues [directly related to] being HIV-positive.”

He acknowledged that the vast improvements in HIV care over time also affected their findings. “There has been so much focus on the treatment of HIV,… but I thought it was still important to report it because many of us thought that there were differences in how these patients got treated [for cardiovascular disease],” Dr. Waksman said.

Since HIV-positive patients receiving antiviral medications cannot tolerate newer-generation antiplatelets like ticagrelor, he explained, “it will be interesting to explore the drug-to-drug interactions” going forward. It could be that there is “no more room to improve outcomes” because HIV-positive patients are not exposed to newer antiplatelets, Dr. Waksman commented.

Source: 
Badr S, Minha S, Kitabata H, et al. Safety and long-term outcomes after percutaneous coronary intervention in patients with human immunodeficiency virus. Catheter Cardiovasc Interv. 2014;Epub ahead of print.