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Kaiser: Elevated MI risk for HIV patients eliminated
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Kaiser Permanente researchers have observed a virtual leveling of the risk for myocardial infarction between patients with and without HIV in their health care system.
“For providers, aggressive conventional risk factor reduction efforts are clearly warranted, coupled with early initiation of antiretroviral treatments to preserve immune function, which can translate into reduced heart disease for patients,” Daniel B. Klein, MD, chief of infectious diseases at Kaiser Permanente San Leandro, Calif., told Infectious Disease News.
Daniel B. Klein
Klein and colleagues evaluated MI risk by HIV status in patients enrolled in Kaiser Permanente’s Northern California and Southern California health plans from 1996 to 2011. The analysis included 24,768 HIV patients and 257,600 demographically matched patients without HIV.
During the study period, there were 320 MIs among HIV patients, or 268 cases/100,000 person-years, and 2,483 MIs among patients without HIV, or 165 cases/100,000 person-years — corresponding with an adjusted rate ratio (RR) of 1.4 (95% CI, 1.2-1.6). The adjusted RR for HIV status declined from 1.8 (95% CI, 1.3-2.6) in 1996-1999 to 1.0 (95% CI, 0.7-1.4) in 2010-2011, according to the researchers.
The researchers also found evidence of comparable or even superior CVD risk profiles for patients with HIV based on Framingham risk scores. In addition, HIV patients had similar increases in prescriptions for lipid-lowering and hypertension therapies as patients without the disease.
Klein and colleagues were among the first to document an elevated risk for MI among HIV patients, which ranged between 40% and 80% in comparison with patients without HIV. The researchers attributed the reduced MI risk since then to increased access to care and CVD risk reduction efforts, including regular reminders for cholesterol and blood pressure monitoring, smoking cessation and diabetes follow-up.
Michael J. Silverberg
Another possible explanation for the dramatic decrease in MI risk is the use of less toxic ART regimens, as well as better management of the disease, the researchers wrote. Early initiation of ART to preserve immune function is also felt to be an important factor in the decline in MI rates observed in this study.
“Such early and sustained improvements in care would have been necessary to achieve not only a reduction in risk of heart attack but a virtual leveling of risk between HIV-positive and HIV-negative individuals,” Michael J. Silverberg, PhD, MPH, a senior research scientist at the Kaiser Permanente Division of Research, said in a press release. “The takeaway from this study is that the well-established higher risk of a heart attack in HIV patients may be reversible. With better HIV treatments, and more attention to traditional cardiovascular risk factors, the difference in risk by HIV status has been diminished or even eliminated.” — John Schoen
For more information:
Klein DB. Clin Infect Dis. 2015;doi:10.1093/cid/civ014.
Silverberg MJ. J Acquir Immune Defic Syndr. 2014;65:160-166.
Disclosure: See the study for a full list of relevant financial disclosures.
Perspective
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Chris Longenecker, MD
This paper is another important contribution to the field of CVD risk in HIV from the Kaiser Permanente system. It's encouraging to see that relatively young, mostly white HIV-positive men with excellent engagement in care may not have a higher risk of myocardial infarction compared to age, gender and calendar-year–matched, HIV-negative controls, although the 95% confidence limits for the adjusted rate ratio for 2010-2011 extends as high as 1.4. As highlighted in their discussion section and in light of prior studies from their group, I agree that these findings may be explained by higher levels of CVD risk prevention efforts over time and access to ART at higher CD4+ T-cell counts. It would be interesting to know what other behavioral factors may have changed over time, such as exercise habits and rates of smoking cessation. Unfortunately, many HIV-positive patients do not match the demographics of this study and do not have access to such coordinated preventive care. Furthermore, these findings may not apply to patients with lower nadir CD4+ T-cell counts who have higher levels of inflammation and immune activation despite ART. This study demonstrates that actively promoting CVD risk prevention for HIV-positive populations might significantly improve outcomes in this traditionally high-risk population.
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