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Ischemic strokes among HIV-infected individuals in the CNICS cohort: the role of traditional and HIV-related risk factors and the impact of events secondary to other causes - Diabetes, HCV, Lipids, Low CD4s Predict Ischemic Stroke With HIV
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Download the PDF here
.....The CNICS team concluded that ischemic strokes predominate in people with HIV....Ischemic strokes related to illicit-drug use or infection represent a unique category of strokes, make up a substantial proportion of ischemic strokes (38%), and differed in both traditional and HIV-related risk factors
18th International Workshop on Comorbidities and Adverse Drug Reactions in HIV, September 12-13, 2016, New York
Mark Mascolini
Low CD4 count and traditional risk factors--including age, race, and comorbid diseases--independently predicted ischemic stroke is a 21,000-person CNICS cohort analysis [1]. More than one third of ischemic strokes could be attributed to illicit drugs or infection, and risk factors differed by ischemic stroke cause.
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[from Jules: What is an ischemic stroke? Ischaemic strokes are the most common type of stroke. They occur when a blood clot blocks the flow of blood and oxygen to the brain. These blood clots typically form in areas where the arteries have been narrowed or blocked over time by fatty deposits known as plaques. This process is known as atherosclerosis......http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Strokes-Clots_UCM_310939_Article.jsp#.V9qBjoVKJek
http://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/documents/downloadable/ucm_309725.pdf
pdf attached
Download the PDF here
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CNICS is a 30,000-person longitudinal HIV cohort study at seven sites in the United States. The CNICS team noted that previous studies of stroke in people with HIV often do not identify stroke type and lack consistent central adjudication of clinical events. To improve the understanding of stroke in HIV-positive people, they developed a centralized stroke adjudication protocol to determine the type and cause of strokes. The analysis reported at the Comorbidities Workshop aimed to define stroke types in the CNICS population, to determine the proportion of ischemic strokes caused by illicit drug use or infection, and to identify risk factors by stroke type.
CNICS investigators created a stroke protocol involving central ascertainment of potential strokes identified by diagnostic codes and a range of possibly related diagnostic or procedure codes. Two neurologists reviewed deidentified packets on each case, and a third neurologist reviewed cases on which the first two neurologists disagreed. The reviewers categorized each stroke by type and subtype and determined whether the stroke was related to infection or illicit drug use.
The analysis involved 20,973 HIV patients from 5 of the 7 CNICS sites. Among 328 strokes identified so far, 262 (80%) were ischemic strokes. The reviewers classified 12% of strokes as hemorrhagic and could not identify the type of the remaining 8%. Among ischemic strokes, subtypes were small vessel (34%), cardioembolic (33%), atheroembolic (21%), and other or unknown (12%). Reviewers attributed 38% of ischemic strokes to infection or illicit drugs.
Next the CNICS team determined demographic and clinical characteristics of cohort members by stroke status: (1) ischemic, not due to drugs or infection (INDI), (2) ischemic due to drugs or infection (IDI), and (3) no ischemic stroke (NS). About three quarters of people in each group were men. INDI patients were older than the other two groups (43% >49 years versus 18% with IDI and 17% with NS. Both stroke groups included a higher proportion of blacks: 59% INDI, 68% IDI, 43% NS. And both stroke groups had higher proportions with a CD4 count of 200 or lower: 38% INDI, 48% IDI, 25% NS.
Cox regression analysis adjusted for traditional and HIV-related stroke risk factors identified 7 independent predictors of ischemic stroke at the following adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI):
-- Each additional year of age: aHR 1.06, 95% CI 1.04 to 1.08, P < 0.01
-- Black vs white race: aHR 1.78, 95% CI 1.24 to 2.55, P < 0.01
-- HCV coinfection: aHR 1.42, 95% CI 1.00 to 2.01, P < 0.01
-- Diabetes: aHR 1.69, 95% CI 1.04 to 2.74, P = 0.03
-- Treated hypertension: aHR 2.26, 95% CI 1.53 to 3.35, P < 0.01
-- Statins for dyslipidemia: aHR 1.83, 95% CI 1.05 to 3.19, P = 0.03
-- Each 100-cell higher time-updated CD4 count: aHR 0.86, 95% CI 0.80 to 0.91, P < 0.01
When the investigators limited the analysis to ischemic strokes not due to infection or illicit drugs, risk factors changed. The protective impact of higher CD4 count on stroke risk diminished, and the association with HCV coinfection disappeared. But diabetes and treated hypertension became stronger predictors of ischemic stroke: for diabetes, aHR 2.26 (95% CI 1.13 to 3.9); and for treated hypertension, aHR 2.44, 95% CI 1.52 to 3.92).
The CNICS team concluded that ischemic strokes predominate in people with HIV. They argued that ischemic strokes caused by infection or illicit drug use make up a unique category that accounts for more than one third of ischemic strokes. And risk factors for strokes not caused by infection or illicit drugs differed from risk factors for all ischemic strokes. Those findings, the CNICS team proposed, "highlight the importance of collecting validated outcomes including both type and cause of the events."
The researchers believe the association of ischemic risk factors with both traditional and CD4-count risk factors "suggests the importance of earlier ART, aggressive management of modifiable traditional risk factors, and targeted management of substance abuse in order to maximally reduce stroke risk" in people with HIV infection.
Reference
1. Crane HM, Nance RM, Chow F, et al. Ischemic strokes among HIV-infected individuals in the CNICS cohort: the role of traditional and HIV-related risk factors and the impact of events secondary to other causes. International Workshop on Comorbidities and Adverse Drug Reactions in HIV, September 12-13, 2016, New York. Abstract 017.
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