Four-year follow-up of more than 40,000 HIV-infected patients revealed no association between longer durations of ART exposure and risk for cardiovascular disease.
Summary
Many antiretroviral regimens have been associated with metabolic perturbations that are linked to risk for atherosclerotic heart disease. Consequently, there is keen interest in determining the rates of cardiovascular events among HIV-infected patients. The first major paper on this subject came from the U.S. Veterans Affairs (VA) system and reported no increased cardiovascular risk with antiretroviral therapy (ART; ACC Apr 1 2003); however, two later reports from the DAD study linked higher rates of cardiovascular disease with increased exposure to ART and, specifically, to PIs (ACC Jan 1 2004 and Apr 25 2007). Now, investigators provide an update on the experience in the VA system.
Data were analyzed from 41,213 HIV-infected patients who were followed for an average of 4 years between 1993 and 2003. Almost all of the patients were men; 52% were black, and 83% were aged 35 to 55. During the observation period, the all-cause mortality rate fell from 20.9 to 5.2 deaths per 100 patient-years. The steepest decline occurred after potent ART first became available, but death rates continued to decrease throughout the next 8 years. The relative hazard for serious cardiovascular disease (defined as inpatient stay for myocardial infarction or the equivalent) was not increased with 2, 3, or 4 years of PI- or NNRTI-based ART, compared with no ART exposure. The authors conclude that ART confers an increasingly powerful survival benefit while posing only a negligible public health risk from cardiovascular effects.
Comment
This report does not provide data about the rates of known cardiovascular risk factors (e.g., smoking, hypertension, and diabetes) or about specific antiretrovirals in this population. The definition used for cardiovascular events would miss premorbid events, such as angina or severe metabolic disturbances, that would be managed initially in the outpatient setting. Curiously, the rate of serious cardiovascular events was lower for blacks than for whites in this study, which is not the case in the general U.S. population. The reassuring results from this updated analysis of the VA study are at odds with much of the published literature in the field, so their applicability to other populations of HIV-infected patients remains unclear.
— Keith Henry, MD
Reviewed by Dr. Ramaz Mitaishvili
Glendale, CA
