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The Impact of Elevated and Pre-hypertensive Systolic Blood Pressure and the Risk of Acute Myocardial Infarction in HIV+ and HIV- Veterans
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Reported by Jules Levin
CROI 2012 March 5-8 Seattle WA
Author Summary: data was analyzed from 84,000+ in the observational VA cohort. HIV+ were matched to uninfected vets. The outcome looked for in this study is incident fatal and nonfatal AMI. The presenter said HIV+ had increased risk of hypertension but the slide words said: systolic & diastolic hypertension are associated with increased AMI risk in HIV+. Second, increased risk for AMI was present even in prehypertension in HIV+. AMI occurred more often in every hypertension level category in HIV+ vs HIV-negs after multivariate analysis. During the Q&A the presenter was asked if HIV+ patients should start hypertension medication early at 130/80 as with diabetics/renal disease and the presenter Armah said this is observational data and he is not yet prepared to recommend that.
They measured blood pressure by using the last 3 measures at the last 3 visits. Amy Justice said the number of visits was 3 vs 4 in the HIV-negs vs the HIV-+ in a given year so there was no difference.
Normal hypertension is defined by JNC7 Blood Pressure Guidelines as <120mmHG systolic pressure & <80 diastolic pressure.
Prehypertension is defined as 120-139 & 80-89 (lifestyle modifications recommended). Stage 1 hypertension is 140-159 systolic & 90-99 diastolic and warrants treatment for hypertension in the general population. Stage 2 hypertension is defined as >/=160 systolic, >/=100 diastolic. If patient has diabetes or renal disease one would be treated for Blood Pressure at <130/80 vs 140-159 in others because these diabetic patients are at greater risk for CVD. Since and we know that HIV also increases risk for CVD perhaps HIV+ individual should also be considered as a special group like diabetics/renal disease and have a different cutoff for hypertension treatment than the general population.
During the Q&A Peter Hunt referred to paper #814 at this CROI in which they reported microbial translocation predicts hypertension suggesting that increased risks for hypertension in HIV+ may be related to increased inflammation and activation, and the presenter said they have markers of inflammation on a subset of patients and should look at them. Dr Sabin asked about the potential role of ART since it has been associated with hypertension & MI rates and the presenter Armah said they were unable to adjust for ARTs because the population was HIV+ and HIV-negs but they are considering doing a subset analysis just within the HIV+. Jaqueline Capeau asked if they looked at the relational with nadir CD4 since nadir CD4 has been found to be associated with CVD and he said he hadn't done that but it's a good point.
AUTHOR CONCLUSIONS:
- treat hypertension in HIV+
- address pre-hypertension in HIV+: we know prehypertension increases risk for progressing to hypertension; so prevent progression to hypertension; in HIV-negatives recommendatio to treat prehypertension is lifestyle modifications in uninfected people & should be used in HIV+.
RESULTS: (n=82,000) at every level of systolic blood pressure the risk for age/race-ethnicity adjusted AMI was greater for HIV+ vs HIV-neg, except for those with rate >140 (SBP) confidence intervals overlapped. The same was found with DPB except there was no overlapping confidence intervals for individuals with hypertension.
At every level of SBP & DBP including the normal ranges HIV+ had greater risk of AMI vs HIV-neg individuals, adjusted for numerous characteristics including lipids, age, race, cocaine, renal disease.
link to webcast:
tp://app2.capitalreach.com/esp1204/servlet/tc?c=10164&cn=retro&s=20481&&dp=player.jsp&e=16637&mediaType=podiumVideo
The Impact of Elevated and Pre-hypertensive Systolic Blood Pressure and the Risk of Acute Myocardial Infarction in HIV+ and HIV- Veterans
Kaku Armah*1, A Justice2,3, K Oursler4,5, M Budoff6, S Brown7,8, A Warner9, M Rodriguez-Barradas10,11, J Baker12, P Hsue13,14, M Freiberg1,15, and the VACS Project Team
1Univ of Pittsburgh Grad Sch of Publ Hlth, PA, US; 2Yale Univ Sch of Med, New Haven, CT, US; 3VA Connecticut Hlthcare System, West Haven, US; 4Univ of Maryland Med Ctr, Baltimore, US; 5VAMC, Baltimore, MD, US; 6Los Angeles Biomed Res Inst at Harbor-UCLA Med Ctr, Torrance, CA, US; 7VAMC, Bronx, NY, US; 8Mt Sinai Sch of Med, New York, NY, US; 9Univ of California, Los Angeles, David Geffen Sch of Med, US; 10Baylor Coll of Med, Houston, TX, US; 11Michael E DeBakey VAMC, Houston, TX, US; 12Univ of Minnesota Med Sch, Minneapolis, US; 13Univ of California, San Francisco, US; 14San Francisco Gen Hosp, CA, US; and 15Univ of Pittsburgh Sch of Med, PA, US
Background: HIV infection is an independent predictor of acute myocardial infarction (AMI) with a magnitude of association similar to that of diabetes mellitus. In the general population, current guidelines recommend more aggressive treatment of blood pressure among those with diabetes. Similar rationale may apply to HIV infection. The objective of this study was to examine whether the association between systolic blood pressure (SBP) and risk for AMI differed by HIV status.
Methods: We analyzed data on 84,444 people from the observational Veterans Aging Cohort Study Virtual Cohort (VC), who were free of cardiovascular diseases at baseline. HIV+ and HIV- veterans were matched 1:2 on age, gender, race/ethnicity, and clinical site. We collected data on SBP and antihypertensive medications, diabetes, dyslipidemia, smoking, hepatitis C, body mass index, renal disease, and substance abuse at baseline and on the incidence of clinically confirmed AMI from October 2003 until September 2008 as part of the VA Ischemic Heart Disease Quality Enhancement Research Initiative. SBP was the average of the three outpatient routine clinical blood pressure measurements performed closest to the baseline date (first clinical visit after April 2003). SBP categories used in the analyses were based on JNC-7 blood pressure criteria. Analyses were performed using Cox proportional hazards regression.
Results: During a median 4.6 years, there were 443 AMI events (47% HIV+). Rates and adjusted hazard ratios (HR) for the risk of AMI stratified by SBP categories and HIV status are presented in the table.
Conclusions: We found that elevated systolic blood pressure is associated with a substantially greater relative risk of AMI among HIV+ than HIV- Veterans. This was true even at pre-hypertensive levels.
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