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Statin Use Cuts All-Cause Mortality 75% in Spanish HIV Cohort
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14th European AIDS Conference. October 16-19, 2013. Brussels.
Mark Mascolini
HIV-positive people who took statins had a 75% lower risk of death from any cause than those who did not in a 733-person study in Spain [1]. Every 100-cell higher nadir CD4 count lowered the risk of death almost 20%.
Previous nationwide research in Denmark [2] and in Baltimore's Johns Hopkins HIV Clinical Cohort [3] linked statin use to a lower death risk in people with HIV. In the 1738-person Danish study, death was 66% less likely in statin takers, but only in those diagnosed with a comorbidity [2]. In the 1538-person Hopkins study, taking statins cut the death risk 67% [3].
Because lipid-lowering statins have an anti-inflammatory effect, their value in HIV-positive people with chronic inflammation has been much discussed and studied. This Spanish analysis included HIV-positive people who had a complete cardiovascular risk assessment in 2002-2004 and at least 6 months of follow-up at an HIV clinic in Barcelona. The investigators counted deaths and ascertained their causes in June 2013.
The study group included 733 adults, 154 of whom (21%) took statins. Average age was significantly older in statin takers (46.1 versus 41.1, P = 0.000), and the statin group included a significantly higher proportion of men (81.8% versus 69.6%, P = 0.003). A significantly higher proportion of people who took statins had a Framingham cardiovascular risk score above 20% (21.4% versus 5%, P = 0.000), and a significantly higher proportion of the statin group had a viral load below 50 copies (63.6% versus 52.5%, P = 0.014). The statin group included a significantly lower proportion of injection drug users (21.4% versus 46.9%), a significantly lower proportion with HCV infection (24.7% versus 47.4%), and a significantly lower proportion of smokers (53.9% versus 70.4%), but statin taken had a significantly higher median total cholesterol (231 versus 178 mg/dL (P = 0.000 for all comparisons).
Through a median follow-up of 10.1 years, 123 people (16.8%) died, including 14 statin takers (9.1%) and 109 (18.8%) who did not take statins. To determine the impact of statin use on all-cause mortality, the researchers used Cox regression analysis adjusted for baseline CD4 cell count, baseline viral load, undetectable viral load at follow-up, Framingham risk score, age, HIV transmission group, chronic liver disease, and smoking status. That analysis determined that taking statins lowered the risk of death 75% (adjusted hazard ratio [aHR] 0.25, 95% confidence interval [CI] 0.1 to 0.61, P = 0.002).
Gender and baseline total cholesterol did not affect mortality in this analysis but five variables had a significant impact, as indicated by the following adjusted hazard ratios (and 95% CIs):
-- Statin use: aHR 0.25 (0.1 to 0.61), P = 0.002
-- Every 10 years of age: aHR 2.04 (1.51 to 2.75), P = 0.000
-- Framingham score above 20%: aHR 2.59 (1.21 to 5.53), P = 0.014
-- Every 100-cell higher nadir CD4 count: aHR 0.82 (0.7 to 0.97), P = 0.023
-- Smoking: aHR 2.48 (1.25 to 4.91), P = 0.024
A viral load below 50 copies halved the death risk, but this association was not statistically significant (aHR 0.50, 95% CI 0.30 to 0.85, P = 0.11).
Malignancy accounted for 7 of the 14 deaths (50%) in statin users, while cardiovascular disease caused 5 deaths (35.7%), AIDS 1 (7.1%), and other causes 1. Among the 109 deaths in the no-statin group, liver failure and malignancy each caused 29 (26.6%), AIDS and other causes each accounted for 19 deaths (17.4%), cardiovascular disease caused 8 deaths (7.3%), and infection caused 5 (4.6%).
Because total cholesterol did not affect death risk in the Cox regression analysis, the researchers proposed that the lipid-lowering impact of statins does not explain their effect on mortality. They cautioned that their findings may not apply to people with different genetic and environmental backgrounds, but the impact on all-cause mortality in this study does not differ greatly from the impact among northern Europeans in Denmark [2] or in a largely African-American population in Baltimore [3].
References
1. Knobel H, Fratchez V, Montero M, et al. The use of statins was associated with reduced mortality in HIV-infected patients. 14th European AIDS Conference. October 16-19, 2013. Brussels. Abstract PE12/7.
2. Rasmussen LD, Kronborg G, Larsen CS, Pedersen C, Gerstoft J, Obel N. Statin therapy and mortality in HIV-infected individuals; a Danish nationwide population-based cohort study. PLoS One. 2013;8(3):e52828.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0052828
3. Moore RD, Bartlett JG, Gallant JE. Association between use of HMG CoA reductase inhibitors and mortality in HIV-infected patients. PLoS One. 2011;6(7):e21843. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0021843
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Reported by Jules Levin
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