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Two Thirds Higher Risk of Death
After MI or Stroke With HIV in Sweden
  European Workshop on Healthy Living With HIV 2019, Barcelona, September 13-14, 2019
Mark Mascolini
HIV-positive people across Sweden have a two thirds higher risk of dying after myocardial infarction (MI) or stroke than HIV-negative people who had an MI or stroke, even after statistical adjustment for age, gender, and tobacco use [1]. Among people with HIV in this nationwide study, older age, injection drug use, and HIV acquisition in Sweden independently boosted risk of MI or stroke.
Cardiovascular disease, including MI and stroke, poses a growing threat to the steadily aging HIV population [2]. Yet cardiovascular risk management remains suboptimal in people with HIV, even in countries with excellent access to health care [3].
Researchers in Sweden conducted a retrospective study to assess the incidence (new-diagnosis rate) of MI and stroke in HIV-positive people across the country. They also aimed to identify MI and stroke risk factors in people with HIV and to compare death risk after MI or stroke in people with versus without HIV. The analysis included people in the Swedish National HIV Registry, the National Patient Register, and SwedeHeart, a national coronary care registry. The investigators used Cox proportional hazards regression models to assess risk factors for MI and stroke in people with HIV and to determine risk of death after MI or stroke with versus without HIV.
Sweden has about 7760 people with HIV, more than 96% of them taking antiretroviral therapy. This analysis focused on 6987 people at least 15 years old and diagnosed with HIV after January 1, 1996. Through a median 9.8 years of follow-up, 364 of these HIV-positive people (5.2%) had an MI or a stroke. Among 312 people admitted to the hospital because of MI or stroke (4.5% of 6987), 27 died (8.6% of 312). Fifty-two people (14.3%) died because of MI or stroke without being admitted to the hospital.
Among people with HIV, proportions with versus without MI or stroke were higher in men than women (6.5% versus 3.1%), higher among drug injectors than other HIV risk groups (13.4% versus 5.4% for gay men and 4.6% for heterosexuals), higher in people born in Sweden than elsewhere (8.9% versus 3.4%), and higher with advancing age.
Cox regression analysis determined that each additional decade of life after age 30 independently raised chances of MI or stroke. For age 31-40 compared with 30 or younger, hazard ratio (HR) 1.91 (95% confidence interval [CI] 1.3 to 2.8, P = 0.001), for age 41-50 HR 2.90 (95% CI 2.0 to 4.3, P < 0.001), for age 51 or older HR 8.71 (95% CI 6.1 to 12.5, P < 0.001). People infected with HIV in Sweden had about a one third higher risk of MI or stroke than people born elsewhere (HR 1.36, 95% CI 1.0 to 1.8, P = 0.020). And people infected while injecting drugs ran almost a doubled risk of MI or stroke than people infected during heterosexual sex (HR 1.97, 95% CI 1.4 to 2.8, P < 0.001).
The next analysis involved 751,889 people at least 15 years old diagnosed with any cardiovascular disease between 1991 and 2018, including 331 people with HIV infection. Age averaged 54.7 in the HIV group and 67.0 in people without HIV. Compared with the HIV-negative group, the group with HIV included a lower proportion of people who never smoked (30.8% versus 50.8%) or never used smokeless tobacco (80.5% versus 86.5%) and higher proportions of current smokers (44.7% versus 19.9%) and current smokeless tobacco users (15.9% versus 8.8%).
Regression analysis adjusted for gender, age, smoking, and smokeless tobacco use determined that people with HIV had a 67% higher risk of dying after MI or stroke than people without HIV (HR 1.67), though that association stopped short of statistical significance (95% CI 0.93 to 3.02, P = 0.088). Every 10 years of age boosted risk of death after MI or stroke more than 10% (HR 1.11, P < 0.001). Compared with people who never smoked, ex-smokers ran a 20% higher risk of dying after MI or stroke (HR 1.20, 95% CI 1.17 to 1.23, P < 0.00) and current smokers ran almost a doubled risk of dying (HR 1.98, 95% CI 1.91 to 2.05, P < 0.001). Compared with people who never used smokeless tobacco, current users had a 10% higher risk of dying after MI or stroke (HR 1.10, 95% CI 1.04 to 1.16, P = 0.001).
The researchers concluded that the high incidence of MI or stroke among HIV-positive people in Sweden underlines the need for stronger cardiovascular disease prevention measures in this population. The higher death risk with HIV after MI or stroke argues for stronger secondary prevention efforts after a cardiovascular event.
1. Marrone G, Storm M. HIV and ageing--Primary and secondary prevention of coronary artery disease among people living with HIV. European Workshop on Healthy Living With HIV 2019. Barcelona. September 13-14, 2019. Abstract 5.
2. Longenecker CT, Sullivan C, Baker JV. Immune activation and cardiovascular disease in chronic HIV infection. Curr Opin HIV AIDS. 2016;11:216-225.
3. van Zoest RA, van der Valk M, Wit FW, Vaartjes I, Kooij KW, Hovius JW, Prins M, Reiss P; AGEhIV Cohort Study Group. Suboptimal primary and secondary cardiovascular disease prevention in HIV-positive individuals on antiretroviral therapy. Eur J Prev Cardiol. 2017;24:1297-1307.
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