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TreatmentUpdate 172

Volume 21 Issue 3

2009 March/April

II COMPLICATIONS AND SIDE EFFECTS - A. Falling rates of heart attacks

Concern about cardiovascular disease—particularly heart attacks and strokes—arose several years after HAART was introduced in high-income countries. This concern was based on increased cholesterol concentrations that are detected in the blood shortly after therapy begins.

However, in 1998 the level of this concern rose after reports of chest pain in two HAART users appeared in a journal. Chest X-rays and other tests revealed that these men had partially blocked arteries. The men were relatively young (27 and 37 years old) and had been using HAART for seven months before they developed symptoms. Both had major risk factors for cardiovascular disease (CVD), as follows:

27 year old – tobacco and cocaine use
37 year old – diabetes and a family history of CVD

Following this, other doctors reported similar cases. These reports spurred research into CVD and HIV. As a result, emerging research suggests that HIV infection increases the risk of CVD in a number of different ways, such as these:

Over the long term, HIV infection appears to be linked to a narrowing of blood vessels. This could increase blood pressure and the chances that unnecessary blood clots may form. Such clots, if large enough, could block the flow of blood, causing tissue damage and heart attacks.
Chronic viral infections—such as HIV—can cause inflammation, damaging the lining of blood vessels. This damage increases the risk of CVD.
Added to this are the increased lipid levels often seen in HAART users.

All of these factors increase the risk of CVD.

To track trends in heart attack and stroke in people who use their services, the large health maintenance organization Kaiser Permanente in California reviewed its giant database focusing on health information captured between 1996 and 2008. The database contained information on more than six million people, about 35,000 of whom are HIV positive. The findings suggest a large and significant decrease in rates of heart attack among HIV positive people.

Details

The study team specifically reviewed information collected on heart attacks and stroke and who sought hospital care for these issues. The profile of HIV positive people in their database was as follows:

10% female, 90% male
age – 41 years

Results—heart attacks

In the years 1998 to 1999, rates of heart attacks had risen and become more common in HIV positive people. After this time, heart attack rates began to decline and by 2008 had fallen to almost the same level as in HIV negative people. Indeed the difference in heart attack rates between HIV positive and HIV negative people was not statistically significant in 2008.

Results—stroke

Rates of stroke were greatest among HIV positive people in the years 1996 to 1997; by 2008, rates of stroke had declined to a point just a bit higher than in HIV negative people. As with heart attack rates, the difference in rate of stroke between HIV negative and HIV positive people was not statistically significant in 2008.

Key points

1. Between 1998 and 2003, the rates of heart attacks and stroke were greater among HIV positive than HIV negative people. However, by 2006, rates of CVD incidents (heart attacks and stroke) began to decline among HIV positive people so that by 2008 the difference in heart attacks was no longer statistically significant.

Rates of strokes were similar in both groups by 2008, in part due to an increased rate of stroke in HIV negative people.

2. According to the study team, the decline in heart attacks and stroke among HIV positive people is probably linked to three things, as follows:

use of more lipid-friendly medicines such as tenofovir (Viread and in Truvada and Atripla) and atazanavir (Reyataz)
increased use of lipid-lowering agents such as statins
reducing traditional risk factors for heart attacks, such as smoking, insufficient exercise, obesity, poor diet and so on

These findings provide hope for HIV positive people and their care providers that heart attacks are not inevitable and the risk for this complication can be greatly reduced.

REFERENCES:

1. Henry K, Melroe H, Huebsch J, et al. Severe premature coronary artery disease with protease inhibitors. Lancet. 1998 May 2;351(9112):1328.

2. Mary-Krause M, Cotte L, Simon A, et al. Increased risk of myocardial infarction with duration of protease inhibitor therapy in HIV-infected men. AIDS. 2003 Nov 21;17(17):2479-86.

3. Hurley L, Leyden W, Xu L, et al. Updated surveillance of cardiovascular event rates among HIV-infected and HIV-uninfected Californians, 1996 to 2008. In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections, February 8-11, 2009, Montreal, Canada. Abstract 710.

4. Fichtenbaum CJ. Metabolic abnormalities associated with HIV infection and antiretroviral. Current Infectious Disease Reports. 2009 Jan;11(1):84-92.

5. Oliviero U, Bonadies G, Apuzzi V, et al. Human immunodeficiency virus per se exerts atherogenic effects. Atherosclerosis. 2009; in press.

Created on: 2009 May 1

Author: Hosein SR

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