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AIDS Drugs Increase Risk of Heart Attack; But Study Indicates Benefit of Therapy Exceeds Threat
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The Washington Post, 11/20/03 HIV Update, November 2003
To read detailed reports of the two studies and an Editorial about HAART & the risk for heart disease, go to this link: http://www.natap.org/2003/nov/112403_7.htm
People infected with HIV who take combination antiretroviral therapy have a slightly higher chance of suffering heart attacks than those who are not on the medicines. But even though the risk accumulates over time, it remains tiny compared with the life-extending benefits of the drugs. That is the conclusion of a large new study that examined the experience of more than 23,000 infected people in 21 countries.
Soon after three-drug combinations for AIDS became popular in 1996, physicians noticed side effects in many patients that included a rise in cholesterol and triglycerides, both risk factors for cardiovascular disease. It was unclear, however, whether the patients actually had more heart attacks.
"In my mind, it settles whether or not there is a link. There is a link," said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Fauci was not involved in the study, which appears in last week's New England Journal of Medicine.
Fred Gordin, an AIDS specialist at the Washington Veterans Affairs Medical Center, said, "This is what all of us have been looking for in terms of proof of the suspicion that these [drug] agents can do harm sometimes, although overall they obviously do more good than harm." Some of his patients were enrolled in the Data Collection on Adverse Events of Anti-HIV Drugs (DAD) Study.
Both experts said the findings are unlikely to change medical practice very much, because most doctors already counsel patients about the possibility of slight increases in heart disease risk from the drugs.
The DAD study enrolled 23,468 patients undergoing treatment at 188 clinics. Some were already taking combination therapy, some subsequently started, and some never did. Three-quarters were men, and their average age was 39. The study followed them for an average of 11/2 years. Over that time, there were 126 heart attacks, about one-quarter of them fatal.
For every year a person was on antiretrovirals, the study found, the risk of a heart attack rose 26 percent above the previous year. This accumulated like compound interest on a savings account, so that after four years a patient had slightly more than twice the risk of a heart attack compared with someone just starting the medicines.
In absolute terms, however, the risk was small. For example, for every 250 people taking antiretrovirals for four years there was one heart attack, on average.
The study suggests that the rise in cholesterol and triglycerides in the blood was responsible for the increased risk. Even before this study, many people on antiretroviral therapy were being prescribed cholesterol-lowering statin drugs. Patients will have to be observed for a longer period to see whether other effects of the AIDS drugs, such as the fact that some can trigger diabetes, are also at play.
While the study was created to help identify the hazards of antiretroviral therapy, it also proved its huge benefit. Before treatment, the patients had an average count of 226 CD4 cells, with 600 to 800 cells being normal. This is evidence of serious, although not irreversible, harm to the immune system, and before the era of combination antiretroviral treatment, the annual mortality for patients with such counts was about 22 percent. With treatment, Lundgren said, about 2 percent of the patients died each year.
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