Myocardial Infarction in People Living with HIV in northern Tanzania

Abstract

Background: People living with HIV (PLWH) are at increased risk for ischemic heart disease (IHD) and myocardial infarction (MI). Our objectives in this study were the following: identify the prevalence of prior MI and myocardial ischemia among PLWH, compare with HIV-uninfected participants, identify correlates of prior MI among PLWH; examine PLWH knowledge, attitudes, and practices (KAP) regarding IHD, identify predictors of improved knowledge, and explore patient and provider perspectives on barriers to MI care. Methods: Adults presenting for routine HIV-care were recruited. Trained research assistants collected basic sociodemographic information and medical history and administered a standardized knowledge, attitudes, and practices survey regarding IHD. An IHD knowledge score between 0 and 10 was calculated for each participant based on the number of correct answers on the KAP knowledge questions. Associations between participant characteristics and IHD knowledge scores were assessed via Welch’s t-test. Age- and sex- matched participants without HIV were selected as controls from an outpatient department in the same district. Both PLWH and control participants underwent 12-lead resting ECG testing. ECG criteria for prior MI was defined as pathologic Q waves in ≥2 contiguous lead and myocardial ischemia as ST segment depression or T wave inversion in ≥2 contiguous leads. Each ECG was reviewed by two independent physician adjudicators, and Pearson’s chi-squared test was used to compare the prevalence of ischemic ECG findings among those with and without HIV. Multivariate logistic regression was also performed to identify patient characteristics correlating with prior MI in PLWH on ECG. Finally, PLWH with ECG findings of prior MI and physicians caring for PLWH were recruited via purposive sampling for in-depth interviews regarding barriers to MI care in PLWH. Inductive thematic analysis was conducted to identify emergent themes and all transcripts were independently coded in NVivo 12. Results: Of 500 enrolled PLWH, the mean (sd) age was 45.3 (11.4) years and 139 were (27.8%) males. The study found an average knowledge score of 5.6, with higher IHD knowledge scores being associated with post-primary education (mean = 6.27 vs 5.35, p = 0.001) and with >10% five-year risk of cardiovascular event (mean = 5.97 vs 5.41, p = 0.045). Control participants without HIV were recruited for 497 participants with HIV. Prior MI (11.1% vs 2.4%, OR 4.97, 95% CI: 2.71-9.89, p<0.001), and myocardial ischemia (18.7% vs 12.1% OR 1.67, 95% CI: 1.18-2.39, p=0.004) were significantly more common among participants with HIV than those without HIV. On multivariate analysis, prior MI among participants with HIV was associated with male sex (OR 2.05, 95% CI: 1.06-3.89, p=0.030) and self-reported family history of cardiovascular disease (OR 2.05, 95% CI: 1.05-3.88, p=0.031). The 24 in-depth interviews of providers and patients revealed barriers related to perceptions and understanding of MI among patients and providers, delays in MI diagnosis and initiation of treatment, and challenges in the provision of long-term MI care. Conclusions: Tanzanians with HIV have a significantly higher burden of IHD than those without HIV, but significant barriers exist to high quality cardiovascular care in this population. Further study is required to characterize cardiovascular disease burden and improve care for PLWH.