Physicians' Academy for Cardiovascular Education

HIV infection increases risk of acute myocardial infarction

Literature - Freiberg MS, Chang C-CH, Kuller LH et al. - JAMA Intern Med. Published online March 4, 2013. doi:10.1001/jamainternmed.2013.3728


HIV Infection and the Risk of Acute Myocardial Infarction


Freiberg MS, Chang C-CH, Kuller LH et al.
JAMA Intern Med. Published online March 4, 2013. doi:10.1001/jamainternmed.2013.3728


Background

Now that people infected with human immunodeficiency virus (HIV) live longer due to the success of antiretroviral therapy (ART), it is important to assess whether HIV is associated with an increased risk of acute myocardial infarction (AMI)[1]. This cohort study compares the incidence of AMI in HIV-positive veterans and demographically and behaviourally similar non-infected veterans. 82 459 veterans without cardiovascular disease were enrolled, of which 33.2% were HIV-positive.


Main results

  • The AMI rates per 1000 person-years were significantly higher among HIV-positive as compared to uninfected veterans, in all age categories.
  • After correcting for Framingham risk factors, comorbidities and substance use, HIV-positive veterans showed an increased risk of AMI as compared to their uninfected controls (HF: 1.48; 95%CI: 1.27-1.72).
  • The risk of AMI in HIV-positive veterans  increases with measures of progressive HIV infection (HIV-1 RNA, CD4 cell count, ART and recent ART/NNRT1/NRT1 regimens).


Conclusions

HIV-positive veterans are at a 50% higher risk of AMI compared to non-infected controls, in addition to the risk explained by commonly acknowledged risk factors. This additional risk is also seen at low HIV-1 RNA levels and low CD4 cell count. The authors suggest that ART may contribute to AMI risk.


Invited commentary by PWG Mallon [2]:

The data of Freiberg and colleagues point to a significant excess risk of AMI in HIV-positive people, the pathogenesis of which we do not clearly understand and which cannot be explained by traditional cardiovascular risk factors or accurately estimated using conventional cardiovascular risk assessments. Taking this into account, presuming that interventions used in the general population to reduce the risk of MI will translate into similar reductions in MI incidence in HIV-positive populations is arguably naive.


References

1. Luther VP, Wilkin AM. HIV infection in older adults. Clin Geriatr Med. 2007;23(3): 567-583, vii.
2. Mallon PWG. 2013. JAMA Intern Med.. doi:10.1001/jamainternmed.2013.264


Abstract

Importance:
Whether people infected with human immunodeficiency virus (HIV) are at an increased risk of acute myocardial infarction (AMI) compared with uninfected people is not clear. Without demographically and behaviorally similar uninfected comparators and without uniformly measured clinical data on risk factors and fatal and nonfatalAMIevents, any potential association between HIV status and AMI may be confounded.

Objective:
To investigate whether HIV is associated with an increased risk of AMI after adjustment for all standard Framingham risk factors among a large cohort of HIV-positive and demographically and behaviorally similar (ie, similar prevalence of smoking, alcohol, and cocaine use) uninfected veterans in care.

Design and Setting:
Participants in the Veterans Aging Cohort Study Virtual Cohort from April 1, 2003,
through December 31, 2009.

Participants:
After eliminating those with baseline cardiovascular disease, we analyzed data on HIV status, age,
sex, race/ethnicity, hypertension, diabetes mellitus, dyslipidemia, smoking, hepatitis C infection, body mass index,renal disease, anemia, substance use, CD4 cell count, HIV-1 RNA, antiretroviral therapy, and incidence of AMI.

Main Outcome Measure:
Acute myocardial infarction.

Results:
We analyzed data on 82 459 participants. During a median follow-up of 5.9 years, there were 871 AMI events. Across 3 decades of age, the mean (95% CI) AMI events per 1000 person-years was consistently and significantly higher for HIV-positive compared with uninfected veterans: for those aged 40 to 49 years, 2.0 (1.6-2.4) vs 1.5 (1.3-1.7); for those aged 50 to 59 years, 3.9 (3.3-4.5) vs 2.2 (1.9-2.5); and for those aged 60 to 69 years, 5.0 (3.8-6.7) vs 3.3 (2.6-4.2) (P_.05 for all). After adjusting for Framingham risk factors, comorbidities, and substance use, HIV-positive veterans had an increased risk of incident AMI compared with uninfected veterans (hazard ratio, 1.48; 95% CI, 1.27-1.72). An excess risk remained among those achieving an HIV-1 RNA level less than 500 copies/mL compared with uninfected veterans in time-updated analyses (hazard ratio, 1.39; 95% CI, 1.17-1.66).

Conclusions and Relevance:
Infection with HIV is associated with a 50% increased risk of AMI beyond that
explained by recognized risk factors.

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