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Worse Prognosis for HIV in Acute Coronary Syndrome: ID Week 2013

Many studies suggest HIV infection confers an increased risk of cardiovascular disease (CVD) even after accounting for traditional risk factors. HIV-infected patients are experiencing higher CVD rates at a time when morality from CVD is declining in the general population. The improvement in survival after CVD events the general population over the past few decades has been attributed to more widely available and more aggressive use of invasive procedures and secondary prevention measures. Only more recently has it been appreciated that HIV-infected individuals have an increased rate of CVD, and with antiretroviral therapy (ART), a life expectancy that warrants aggressive interventions. Silverberg et al. used the Kaiser Permanente database to evaluate mortality in HIV-infected patients experiencing acute coronary syndrome (ACS). From 1996-2010, 226 HIV-infected patients and 66,321 HIV uninfected patients were identified. The HIV group was younger, had fewer females, were diagnosed more often in the later years of the study, were more likely to have an S-T elevation MI, had higher HDL and triglycerides and smoked more than the HIV-negative group. Raw mortality did not differ between groups, but after adjustment for multiple variables, HIV-infected patients had a 2.2 and 2.5-fold increase in mortality at one and three years, respectively. Compared to HIV-negatives, HIV-positive patients with a CD4 count <200 or 200-499 had a 5.6- and 2.5-fold adjusted increase in mortality, respectively. Mortality in those with a CD4 >500 did not differ from the HIV-negative group. Those on no ART or PI-based ART also had adjusted increased mortality (3.4 and 2.5-fold, respectively) compared to HIV-uninfected patients, while those on ART without a PI did not have significantly increased mortality. Data on treatment utilization was not included in the presentation, so the observed differences in mortality might have resulted from differential use of interventions. Also, because the investigators could not ascertain cause of death, it remains uncertain if the increased mortality observed in the HIV group was due to cardiovascular disease, other comorbid conditions or HIV itself. Nevertheless, this study suggests ACS carries a more ominous prognosis in HIV and may warrant more aggressive treatment. Low CD4 counts and PI use have been linked previously to increased risk for development of CVD. This report suggests these factors also influence prognosis once clinical CVD event occur and support the current emphasis on earlier HIV diagnosis and treatment initiation.

Silverberg M, Hurley L. Prasad A et al. Mortality following hospitalization for acute coronary syndrome among HIV+ and HIV- patients. ID Week 2013, San Francisco, CA, October 2-6, 2013, abstract 759.

Source: Reporting from San Francisco for PRN News: David H Shepp, MD