Elevated N-terminal prohormone of brain natriuretic peptide among persons living with HIV in a South African peri-urban township

Imaging and Circulating Biomarker-Defined Cardiac Pathology in Pulmonary Tuberculosis: A Systematic Review

Background

Pulmonary tuberculosis (PTB) is associated with increased cardiovascular disease (CVD) mortality. However, underlying pathophysiological mechanisms are poorly understood. This systematic review aims to synthesise the evidence on the prevalence of cardiac pathology based on cardiac imaging and circulating biomarkers in patients with PTB.

Methods

We systematically searched databases for studies in patients with PTB evaluating cardiac pathology (pericardial effusion or left ventricular dysfunction) on echocardiography; late gadolinium enhancement on cardiac magnetic resonance imaging (CMR); myocardial inflammation on positron-emission tomography (PET); coronary artery stenosis on CT coronary angiography (CTCA); and cardiac troponin (cTn) and/or B-type natriuretic peptides (BNP) assessment.

Results

Seven studies were included across 1,333 participants with PTB. Four studies used echocardiography (n = 1,111). The prevalence of pericardial effusion ranged from 14.1-55.9%; and left ventricular systolic impairment from 0-4.25%. One study used CMR and PET-CT (n = 26); and two studies used PET-CT alone (n = 196). The prevalence of pericardial and/or myocardial inflammation ranged from 0.6-21.8%. One study evaluated cTn, Creatine Kinase-MB (CK-MB), and BNP (n = 800), of whom 246 had raised cTn. No study reported cardiac pathology using CTCA.

Conclusion

Pericardial effusion is the commonest reported cardiac pathology in PTB. To date, only one study has evaluated cardiac biomarkers and studies evaluating myocardial or coronary disease on advanced imaging remain limited. Our study highlights the paucity of evidence on the presence of cardiac pathology in PTB. Studies are required to determine the prevalence of, and disease mechanisms associated with cardiac pathology among patients with PTB.

Antiretroviral therapy and HIV-associated cardiovascular disease: a prospective cardiac biomarker and CMR tissue characterization study

AIMS

Biochemical markers are fundamental in cardiac evaluation, and various novel assays have recently been discovered. We prospectively evaluated the hearts of newly diagnosed people living with human immunodeficiency virus (PLWH) using cardiac biomarkers, compared them with human immunodeficiency virus (HIV)-uninfected controls, and correlated our prospective findings with cardiovascular magnetic resonance imaging (CMR).

METHODS AND RESULTS

Newly diagnosed, antiretroviral therapy (ART)-naïve PLWH were recruited along with HIV-uninfected, age-matched, and sex-matched controls. All participants underwent measurement of high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), soluble ST2 (sST2), and galectin-3, as well as a CMR study with multiparametric mapping. The HIV group started ART and was re-evaluated 9 months later. The cardiac biomarkers and their correlation with CMR parameters were evaluated in and between groups. Compared with controls (n = 22), hs-cTnT (4.0 vs. 5.1 ng/L; P = 0.004), NT-proBNP (23.2 vs. 40.8 ng/L; P = 0.02), and galectin-3 (6.8 vs. 9.0 ng/mL; P = 0.002) were all significantly higher in the ART-naïve group (n = 73). After 9 months of ART, hs-cTnT (5.1 vs. 4.3 ng/L; P = 0.02) and NT-proBNP (40.8 vs. 28.5 ng/L; P = 0.03) both decreased significantly and a trend of decrease was seen in sST2 (16.5 vs. 14.8 ng/L; P = 0.08). Galectin-3 did not demonstrate decrease over time (9.0 vs. 8.8 ng/mL; P = 0.6). The cardiac biomarkers that showed the best correlation with CMR measurements native T1, T2, and extracellular volume were NT-proBNP (rs ≥ 0.4, P < 0.001) and galectin-3 (rs ≥ 0.3, P < 0.01).

CONCLUSIONS

Our cardiac biomarker data support the presence of subclinical myocardial injury, remodelling, and fibrosis at HIV diagnosis, and ART had a positive influence on these blood markers. It remains unclear if the underlying pathological processes were fully addressed by ART. The ability of cardiac biomarkers to detect and track tissue abnormalities diagnosed with CMR showed promise. With additional research, this could lead to improvements in screening and monitoring myocardial abnormalities, even in CMR-limited settings.

Human Immunodeficiency Virus Infection-Associated Cardiomyopathy and Heart Failure

The landscape of human immunodeficiency virus (HIV) epidemiology and treatment is ever-changing, with the widespread and evolving use of antiretroviral therapy (ART). With timely ART, people living with HIV (PLWH) are nearing the life expectancies and the functionality of the general population; nevertheless, the effects of HIV and ART on cardiovascular health remain under investigation. The pathophysiology of HIV-related cardiomyopathy and heart failure (HF) have historically been attributed to systemic inflammation and changes in cardiometabolic function and cardiovascular architecture. Importantly, newer evidence suggests that ART also plays a role in modulating the process of HIV-related cardiomyopathy and HF. In the short term, newer highly active ART (HAART) seems to have cardioprotective effects; however, emerging data on the long-term cardiovascular outcomes of certain HAART medications, i.e., protease inhibitors, raise concerns about the potential adverse effects of these drugs in the clinical course of HIV-related HF. As such, the traditional phenotypes of dilated cardiomyopathy and left ventricular systolic failure that are associated with HIV-related heart disease are incrementally being replaced with increasing rates of diastolic dysfunction and ischemic heart disease. Moreover, recent studies have found important links between HIV-related HF and other clinical and biochemical entities, including depression, which further complicate cardiac care for PLWH. Considering these trends in the era of ART, the traditional paradigms of HIV-related cardiomyopathy and HF are being called into question, as is the therapeutic role of interventions such as ventricular assist devices and heart transplantation. In all, the mechanisms of HIV-related myocardial damage and the optimal approaches to the prevention and the treatment of cardiomyopathy and HF in PLWH remain under investigation.

Predictors of COVID-19 Vaccine Hesitancy in South African Local Communities: The VaxScenes Study

South Africa launched a mass COVID-19 vaccination campaign in May 2021, targeting 40 million adults. Understanding predictors of COVID-19 vaccine intentions was required to achieve this goal. We conducted a population-based survey in June-July 2021 using the WHO Behavioral and Social Drivers (BeSD) of COVID-19 Vaccination tool to determine predictors of vaccine hesitancy, defined as intention to refuse or uncertainty whether to accept COVID-19 vaccination. There were 1193 participants, mean age 39 (standard deviation 15) years, and 53% women, of whom 58% trusted information provided by healthcare workers and 32% were vaccine hesitant. Independent predictors of vaccine hesitancy included concerns about side effects (odds ratio (OR) 11.41; 95% confidence interval (CI) 3.5-50.80), lack of access to the online vaccine registration platform (OR 4.75; CI 2.15-10.37), distrust of government (OR 3.0; CI 1.33-6.77), belief in conspiracy theories (OR 3.01; CI 1.32-6.77), having no monthly income (OR 1.84; CI 1.12-3.07), and depending on someone else to make vaccination decision (OR 2.47; CI 1.06-5.77). We identified modifiable predictors of vaccine hesitancy at the start of South Africa's COVID-19 vaccination rollout. These factors should be addressed by different stakeholders involved in the national immunization program through tailored communication and other effective strategies that increase vaccine literacy, reach low-income households, and engender confidence in government.

Elevated N-terminal prohormone of brain natriuretic peptide among persons living with HIV in a South African peri-urban township

AIMS

Efforts to improve access to antiretroviral therapy (ART) have shifted morbidity and mortality among persons living with HIV (PLWH) from AIDS to non-communicable diseases, such as cardiovascular disease (CVD). However, contemporary data on CVD among PLWH in sub-Saharan Africa in the current ART era are lacking. The aim of this study was to assess the burden of cardiac stress among PLWH in South Africa via measurement of N-terminal prohormone of brain natriuretic peptide (NT-proBNP).

METHODS AND RESULTS

NT-proBNP was measured at baseline in 224 PLWH enrolled in a sub-study of a tuberculosis vaccine trial in Khayelitsha township near Cape Town, South Africa. Thresholds were applied at the assay's limit of detection (≥137 pg/mL) and a level indicative of symptomatic heart failure in the acute setting (>300 pg/mL). Mean (SD) age of participants was 39 (6) years, 86% were female, and 19% were hypertensive. Mean (SD) duration of HIV diagnosis was 8.3 (3.9) years and CD4 + count was 673 (267) with 79% prescribed ART for a duration of 5.6 (2.7) years. Thirty-one percent of participants had NT-proBNP > 300 pg/mL. Elevated vs. undetectable NT-proBNP level was associated with older age (P = 0.04), no ART (P = 0.03), and higher plasma tumour necrosis factor-α (P = 0.01).

CONCLUSIONS

Among South African PLWH largely free of known CVD and on ART with high CD4 + counts and few comorbidities, we observed a high proportion with elevated NT-proBNP levels, suggesting the burden of cardiac stress in this population may be high. This observation underscores the need for more in-depth research, including the current effect of HIV on heart failure risk among a growing ART-treated population in sub-Saharan Africa.