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A Firmer Link Between HIV and Cardiovascular Disease

Summary and Comment |
March 18, 2013

A Firmer Link Between HIV and Cardiovascular Disease

  1. Abigail Zuger, MD

A huge, well-controlled study affirms that HIV infection, whether treated or not, is an independent cardiovascular risk factor.

  1. Abigail Zuger, MD

Despite much study, the connection between HIV and coronary heart disease (CHD) remains tantalizingly difficult to confirm, in part because few studies have been able to definitively control for all the more traditional cardiovascular risk factors. Now, researchers have followed up a large prospective cohort of more than 82,000 veterans (mean age, 48; 97% men; 48% black) from 2003 through 2009 for development of myocardial infarction (MI). About one third of participants were HIV infected, and at baseline about half of these individuals were receiving antiretroviral therapy (ART).

At study entry, CHD risk by Framingham criteria was intermediate for both HIV-infected and HIV-uninfected participants (Framingham risk score=6). After about 6 years, 871 acute MIs had been diagnosed in the cohort. After adjustment for standard Framingham risk factors, comorbid disease, and substance use, MI risk was 50% higher among the HIV-infected participants than among the uninfected. This elevated risk persisted in the absence of other risk factors for MI, including hepatitis C virus infection, renal disease, and anemia. When results were parsed by age, HIV infection conferred a significant risk among participants who were 40 to 49, 50 to 59, or 60 to 69, but not among younger or older participants.

Within the HIV-infected group, baseline CD4-cell count, viral load, and ART did not influence MI risk, although recent immunologic or virologic evidence of uncontrolled infection was associated with elevated risk. Among individual components of ART, only protease inhibitor use had borderline significance as an MI risk factor.

Comment

This study's large numbers are difficult to argue with, and its specifics suggest that despite the metabolic effects of ART, it is HIV infection itself that carries the larger cardiovascular risk. An editorialist wonders whether persistent systemic inflammation even in the presence of effective ART may underlie this observation.

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