European Journal of Cardiovascular Medicine

In recent decades, Human Immunodeficiency Virus (HIV) infection has become a chronic, manageable condition due to widespread implementation of antiretroviral therapy (ART) and integrated counseling and testing centers (ICTCs). This has significantly reduced the burden of opportunistic infections and improved life expectancy among people living with HIV (PLHIV). However, with increased longevity, a shift in the disease burden has been observed towards non-communicable diseases, particularly cardiovascular complications (1,2).

Electrocardiography (ECG) remains one of the most accessible, non-invasive, and cost-effective diagnostic tools for detecting both acute and chronic cardiac abnormalities. Among PLHIV, ECG plays a crucial role in early recognition of subclinical myocardial changes and arrhythmias (1,3). Several studies have highlighted that HIV-related systemic inflammation, metabolic alterations induced by ART, and immune dysregulation collectively increase the risk of cardiovascular disease in this population (3,4).

C-reactive protein (CRP), a well-established biomarker of systemic inflammation, has emerged as a useful predictor of cardiovascular risk. Elevated CRP levels have been associated with a higher incidence of myocardial infarction, atherosclerosis, and vascular injury, even in asymptomatic patients (4-6). In PLHIV, elevated CRP levels reflect ongoing immune activation and may serve as a surrogate marker for cardiovascular morbidity and mortality (5,6).

Given this context, the present study investigates the electrocardiographic abnormalities observed in PLHIV and evaluates their correlation with serum CRP levels. This correlation may offer a simple and practical approach to stratifying cardiovascular risk in HIV-infected individuals, thereby enabling timely interventions and reducing long-term complications (7,8).a

This prospective observational study was conducted at the Antiretroviral Therapy (ART) Centre of a tertiary care teaching hospital from December 2020 to October 2022. Ethical clearance was obtained from the institutional ethics committee prior to the commencement of the study. All participants were informed about the study protocol, and written informed consent was obtained from each individual before enrollment.

Study Population

A total of 50 patients living with HIV (PLHIV), aged 18 years and above, attending the ART Centre either for routine follow-up or hospitalization, were included in the study. All participants were confirmed HIV-positive as per NACO guidelines.

Inclusion Criteria

• HIV-positive patients aged 18 years or older.
• Patients who provided informed written consent.

Exclusion Criteria

• Known history of hypertension or pre-existing cardiovascular disease diagnosed prior to HIV infection.
• History of alcohol consumption exceeding 5 years duration.
• Patients currently on treatment for any other chronic systemic illness that may influence cardiovascular outcomes.

Study Procedure

Detailed clinical history and examination were performed for all participants. A standard 12-lead Electrocardiogram (ECG) was recorded for each patient to detect any cardiac abnormalities. The ECGs were analyzed for changes such as ST-segment elevation, T-wave inversion, sinus tachycardia, irregular rhythm, left ventricular hypertrophy (LVH), and electrical alternans.

Simultaneously, serum C-reactive protein (CRP) levels were measured using a high-sensitivity immunoturbidimetric assay, and values were recorded in mg/dL. The CRP levels were then correlated with the ECG findings.

Statistical Analysis

Descriptive statistics were used to represent demographic data and ECG abnormalities. The association between ECG findings and serum CRP levels was analyzed using the Chi-square test, and a p-value < 0.05 was considered statistically significant.

A total of 50 patients living with HIV were evaluated for electrocardiographic abnormalities and correlated with serum CRP levels. The demographic characteristics and ECG findings are summarized in the tables below.

Table 1: Distribution of ECG Abnormalities among PLHIV

[Table 1] shows that T wave inversion was the most frequently observed abnormality (58%), followed by ST-segment elevation (24%). Other findings, including sinus tachycardia, irregular rhythms, LVH patterns, and electrical alternans, were observed in 4–2% of the patients. Only 2 patients (4%) demonstrated a normal ECG pattern.

Table 2: Correlation of Serum CRP Levels with ECG Changes

[Table 2] demonstrates that all patients with ST segment elevations had elevated CRP levels, with 60% having CRP values greater than 100 mg/dL. Among patients with T wave inversions, 93% had raised CRP, and 24% exceeded the 100 mg/dL mark. In contrast, none of the patients with a normal ECG had elevated CRP levels, indicating a strong correlation between inflammatory status and ECG abnormalities.

Furthermore, overall, 95% of patients with ST-T changes (ST elevations and T wave inversions) had elevated serum CRP levels, suggesting a statistically significant association (p < 0.001) between inflammatory markers and cardiovascular involvement in PLHIV.

Out of all 50 patients, 13 individuals had serum CRP levels greater than 100 mg/dL. Among them, the majority had either ST-segment elevations or T wave inversions, indicating increased risk of morbidity and mortality in this subgroup.

These results support the hypothesis that inflammatory processes, as indicated by CRP elevation, play a key role in the pathogenesis of cardiovascular abnormalities in HIV-positive individuals.

This prospective observational study aimed to evaluate electrocardiographic changes in people living with HIV (PLHIV) and to assess their correlation with serum C-reactive protein (CRP) levels. The findings of this study suggest that cardiovascular abnormalities are frequently observed in PLHIV, even in the absence of traditional risk factors, and that elevated serum CRP levels are significantly associated with such electrocardiographic changes.

In our study, the most common ECG abnormalities included T wave inversions (58%) and ST segment elevations (24%), indicating myocardial repolarization disturbances and possible ischemic changes. These findings are consistent with previous studies which have reported high prevalence of ECG abnormalities among PLHIV, often linked to chronic inflammation, immune activation, and cardiotoxic effects of antiretroviral therapy (1,2).

Elevated serum CRP levels were present in 95% of patients with ST-T changes, and 60% of those with ST elevations had CRP levels exceeding 100 mg/dL. This strong association supports earlier reports highlighting CRP as an independent predictor of cardiovascular events in HIV-infected individuals (3,4). Inflammatory markers such as CRP are believed to reflect the extent of vascular injury and immune-mediated endothelial dysfunction, both of which are central to the pathogenesis of HIV-related cardiovascular disease (5-9).

Interestingly, only 4% of the patients had normal ECG findings, and these individuals also had normal CRP levels, suggesting that the absence of ECG changes may correlate with low inflammatory burden and reduced cardiovascular risk. Previous literature confirms that CRP levels are predictive of both clinical and subclinical atherosclerosis in HIV-positive cohorts, regardless of ART status (10-12).

The significant correlation between elevated CRP levels and ECG abnormalities (p < 0.001) observed in our study reinforces the utility of CRP as a screening tool for early cardiovascular risk assessment in HIV-infected populations. Moreover, studies have shown that PLHIV with high CRP levels are more prone to acute coronary syndromes and other major adverse cardiovascular events (13-15).

The findings of this study underscore the importance of routine ECG monitoring and CRP measurement in PLHIV, especially those with long-standing infection or on prolonged ART. Early identification of cardiovascular risk can facilitate timely intervention, potentially reducing morbidity and mortality in this vulnerable population.

This study highlights that cardiovascular abnormalities are common in people living with HIV and are strongly associated with elevated serum CRP levels. Electrocardiography, combined with CRP measurement, serves as an effective, non-invasive approach for early detection of cardiovascular risk in PLHIV, aiding in timely intervention to reduce morbidity and mortality.

1. Befkadu Z, Ibrahim M, Tadelle A, Tegene E. Electrocardiographic abnormalities and associated factors among HIV-infected adults on antiretroviral therapy. Front Reprod Health. 2024 Sep 10;6:1387464.
2. Sinamaw D, Getnet M, Abdulkadir M, Abebaw K, Ebrahim M, Diress M, et al. Patterns and associated factors of electrocardiographic abnormality among type 2 diabetic patients in Amhara National Regional State Referral Hospitals, Ethiopia: a multicenter institution-based cross-sectional study. BMC Cardiovasc Disord. 2022 May 19;22(1):230.
3. Bedane DA, Tadesse S, Bariso M, Reta W, Desu G. Assessment of electrocardiogram abnormality and associated factors among apparently healthy adult type 2 diabetic patients on follow-up at Jimma Medical Center, Southwest Ethiopia: Cross-sectional study. BMC Cardiovasc Disord. 2021 Jun 24;21(1):312.
4. Girma B, Wondie A, Debebe W, Juhar A, Tegene E, Bedane D, et al. Electrocardiogram abnormalities and associated factors among psychiatric patients attending follow up at Jimma Medical Center Psychiatry Clinic, Jimma, Ethiopia: an institution-based cross-sectional study. BMC Cardiovasc Disord. 2023 Apr 1;23(1):178.
5. Zenu S, Tesema T, Reshad M, Abebe E. Determinants of first-line antiretroviral treatment failure among adult patients on treatment in Mettu Karl Specialized Hospital, South West Ethiopia: a case control study. PLoS One. 2021 Oct 22;16(10):e0258930.
6. Shen F, Zhu B, Ding Y, Gao M, He N. Electrocardiographic abnormalities among people with HIV in Shanghai, China. Biosci Trends. 2020 Mar 16;14(1):9-15.
7. Worku WZ, Azale T, Ayele TA, Mekonnen DK. HIV is still a major public health problem among pregnant women attending ANC in Referral Hospitals of the Amhara Regional State, Ethiopia: a cross-sectional study. BMC Womens Health. 2022 Nov 24;22(1):468.
8. Wasihun Y, Asnake D, Kebede N. Investigating factors associated to HBV/HIV co-infected patients in antiretroviral treatment clinic, in Northeast Ethiopia. BMC Infect Dis. 2024 May 1;24(1):460.
9. Kefeni BT, Hajito KW, Getnet M. Renal function impairment and associated factors among adult HIV-positive patients attending antiretroviral therapy clinic in Mettu Karl Referral Hospital: cross-sectional study. HIV AIDS (Auckl). 2021 Jun 9;13:631-640.
10. Ding Y, Zhu B, Lin H, Chen X, Shen W, Xu X, et al. HIV infection and electrocardiogram abnormalities: baseline assessment from the CHART cohort. Clin Microbiol Infect. 2020 Dec;26(12):1689.e1-1689.e7.
11. Adane T, Melese M, Tesfaye E, Ambelu A, Getnet M, Sinamaw D, et al. Electrocardiogram abnormalities and associated factors among people with and without epilepsy attending the outpatient department at referral hospitals in Amhara Regional State, Northern Ethiopia, 2022: institutional-based comparative cross-sectional study. Neuropsychiatr Dis Treat. 2023 May 30;19:1285-1302.
12. GebreEyesus FA, Tarekegn TT, Amlak BT, Shiferaw BZ, Emeria MS, Geleta OT, et al. Levels and predictors of anxiety, depression, and stress during COVID-19 pandemic among frontline healthcare providers in Gurage zonal public hospitals, Southwest Ethiopia, 2020: a multicenter cross-sectional study. PLoS One. 2021 Nov 29;16(11):e0259906.
13. Soliman EZ, Prineas RJ, Roediger MP, Duprez DA, Boccara F, Boesecke C, et al. Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study. J Electrocardiol. 2011 Nov-Dec;44(6):779-85.
14. Molla AA, Gelagay AA, Mekonnen HS, Teshome DF. Adherence to antiretroviral therapy and associated factors among HIV positive adults attending care and treatment in University of Gondar Referral Hospital, Northwest Ethiopia. BMC Infect Dis. 2018 Jun 8;18(1):266.
15. Gelagay AA, Koye DN, Yeshita HY. Demand for long acting contraceptive methods among married HIV positive women attending care at public health facilities at Bahir Dar City, Northwest Ethiopia. Reprod Health. 2015 Aug 27;12:76.