ESC Congress 2026 Abstract · Oct 26, 2026
Long term prognostic value of silent myocardial ischaemia in asymptomatic people with HIV
By Bailly G, Soulat-Dufour L, Rousseau A et al.
Background and Aims: People living with HIV (PWH) are at higher risk of coronary heart disease (CHD). There is a need for improved cardiovascular (CV) risk stratification. We assessed the long-term prognostic value of silent myocardial ischaemia (SMI) for major adverse cardiovascular events (MACE) in asymptomatic PWH without known CHD. Methods: Between 2003 and 2016, consecutive asymptomatic PWH without known CHD underwent systematic CV evaluation, including non-invasive screening for CHD. Clinical events were collected up to 2023. The primary endpoint was 4-point MACE (CV death, non-fatal myocardial infarction, non-fatal stroke, or coronary revascularisation). Secondary endpoints were 3-point MACE, coronary events, and all atherothrombotic events. Predicted risk using SCORE2 and ASCVD risk scores was compared with observed risk. Results: Among 810 eligible PWH, overall loss to follow-up was exceptionally low at 0.6% (5/810). The final analysis included 756 participants (mean age 51.1 ± 8.3 years; 85.3% men) with long-standing, well-controlled HIV (median known duration 19.8 years; 15.9 years on ART; 89% virologically suppressed). Median SCORE2 and ASCVD risk scores were 3.7 (IQR 2.5–5.5) and 6.0 (IQR 3.0–11.0), respectively. Among 756 participants, 29 (3.8%) had a positive ischaemia test at baseline. Over a median follow-up of 11.0 years, the 10-year cumulative incidence of CV events was 18.4%. These events were significantly more frequent in patients with a positive vs negative test (39.3% vs 17.5%; P = 0.004). The primary endpoint (4-point MACE) occurred in 8.5% of the cohort (incidence 9.7/1,000 person-years), with significantly lower 10-year event-free survival in the positive test group (log-rank P = 0.009).This difference was consistent across all secondary endpoints (all log-rank P ≤ 0.03). Sudden cardiac death accounted for 57.7% of CV deaths. In multivariable analysis, a positive baseline stress test was independently associated with 4-point MACE (adjusted HR 2.42, 95% CI 1.03–5.68; P = 0.043). HIV-specific variables (including HIV seropositivity duration and cumulative ART exposure) were not associated with outcomes. Risk prediction using SCORE2 and ASCVD was modest (C-statistics 0.64 and 0.63, respectively) with discordant calibration patterns. Specifically, SCORE2 underestimated risk in low-to-moderate categories, while ASCVD overestimated it. Conclusions: In asymptomatic PWH without known CHD, SMI was infrequent (3.8%) but independently associated with a 2.4-fold higher risk of 4-point MACE over long-term follow-up, identifying a high-risk cardiovascular phenotype. Conventional risk scores showed modest discrimination and imperfect calibration. These findings highlight the heterogeneity of cardiovascular risk in asymptomatic PWH and support targeted non-invasive ischaemia testing for risk refinement.Kaplan–Meier survival curves for 4-P MACEAdjusted/unadjusted Cox regression for 4PMACE