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Short-Term Mortality After Heart Attack With HIV Fell Over Past Decade in D:A:D
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20th Conference on Retroviruses and Opportunistic Infections, March 3-6, 2013, Atlanta
Mark Mascolini
Mortality in the month after myocardial infarction (MI) fell from 26% to 8% over the last decade in the D:A:D Study [1]. The decline could be traced to greater use of invasive cardiovascular procedures and heart medicines--not to changes in the MI population--from 1999 to 2011. But a fair proportion of D:A:D MI patients were still not getting standard post-MI treatments by the end of follow-up.
Much research examines cardiovascular disease risk in people with HIV, but few studies have assessed clinical outcomes after myocardial infarction, even over the short term. That question was addressed by researchers with D:A:D--the ongoing study of adverse events in people with HIV in Europe, Australia, and the United States. They focused on people who had an MI between December 1999 and February 2011. The D:A:D team used logistic regression to assess associations between calendar year and death in the first month after MI diagnosis. The model adjusted for a wide array of classic and HIV-related cardiovascular risk factors (see poster at link below). The researchers then further adjusted the model for interventions in the first month after MI in 703 people who survived more than 1 day after their heart attack.
The study team identified 844 MIs, 501 of them definite and 200 possible, with the remaining 143 "unclassifiable." There were 212 MIs in 1999-2002, 194 in 2003-2004, 157 in 2005-2006, 171 in 2007-2008, and 110 in 2009-2111. Of the 844 people who had a heart attack, 770 (91%) were men and 482 (57%) white. Almost everyone, 95.5%, had taken antiretroviral therapy, more than half (53%) were current smokers, 14% had a family history of cardiovascular disease, 8% had a previous MI, 8% had a previous invasive cardiovascular procedure, and 4% had a previous stroke. Median CD4 count stood at 444, and 61% had a viral load at or below 50 copies.
The proportion of people with a high Framingham Risk Score (greater than 20% 10-year risk) did not change much over time: 28.8% in 1999-2002, 23.2% in 2003-2004, 22.3% in 2005-2006, 26.9% in 2007-2008, and 32.7% in 2009-2011. Some variables did tend to change over time--age at MI dropped, the proportion of whites fell, the proportion on antiretroviral therapy with a suppressed viral load rose, and average CD4 count climbed. But the researchers observed that these changes reflect those seen in the D:A:D population over this period.
Over a median follow-up of 33 months, 88 of 844 MI patients (10%) had another MI and 281 people (33%) died. Of those 281 deaths, 172 (61%) occurred in the first month after the MI to yield a short-term mortality of 20.4%. Cardiovascular disease caused 91% of deaths in the first month after MI but caused only 39% of deaths that happened more than a month after MI.
Over the study period use of invasive coronary procedures after MI rose from 42.7% in 1999-2002 and 57.1% in 2003-2004 to 63% or higher in the next three study periods. Among people who had not received the following treatments before their MI and surviving more than 1 day after their MI, 44% started lipid-lowering drugs, 52% started antiplatelets, 27% started angiotensin-converting enzyme (ACE) inhibitors, and 41% started antihypertensives.
The proportion of MI patients who died in the month after their heart attack dwindled steadily over the study period: 26.4% in 1999-2002, 24.7% in 2003-2004, 19.8% in 2005-2006, 16.4% in 2007-2008, and 8.2% in 2009-2011. Statistical analysis not adjusted for other risk factors determined that chances of death in the first month after MI fell 12% every year (odds ratio [OR] 0.88, 95% confidence interval [CI] 0.83 to 0.94).
Adjusting this analysis for baseline characteristics (such as injection drug use, CD4 count at MI, and family history) did not change odds of dying at all (adjusted OR 0.88). But when the D:A:D team further adjusted the analysis for increasing use of invasive procedures or heart medications in the first month after MI (Figure 1 in poster linked below), the declining odds of dying over the years vanished (adjusted OR 1.02, 95% CI 0.94 to 1.10). That result suggested to the investigators that "use of these interventions may have played a role in the increased survival rate."
The D:A:D investigators concluded that "the improvement in short-term survival post-MI that we have seen since 1999 appears to be largely driven by improved patient management post-MI." Still, they pointed out, some MI patients with HIV did not appear to receive standard treatment, a finding they believe raises several questions:
-- Does it reflect under-ascertainment or delayed ascertainment of information on receipt of such interventions in study databases?
-- Is the intervention rate in people with HIV similar to that in the general population?
-- Have D:A:D participants received other interventions, such as advice on diet, smoking, or exercise, that are not captured in the D:A:D dataset?
The D:A:D team plans to pursue this research to assess longer-term outcomes and associations between pre-MI CD4 count and mortality.
Reference
1. Sabin C, Ryom L, Law M, et al. Improvements in short-term mortality following myocardial infarction: the Data Collection on Adverse Events of Anti-HIV Drugs Study. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 748. http://www.cphiv.dk/portals/0/files/CROI%202013_DAD_CS.pdf
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