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Heart Failure Diagnosed 6 to 16 Years Earlier in Veterans With vs Without HIV
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11th International Workshop on HIV & Aging Virtual Meeting, September 30 to October 2, 2020
By Mark Mascolini for NATAP and Virology Education
US veterans with HIV infection get diagnosed with heart failure 6 to 16 years earlier than veterans without HIV, depending on the statistical method used [1]. Heart failure diagnosis at a younger age with HIV proved consistent across several subgroups, including inpatients versus outpatients, ejection fraction above or below 45%, and calendar period of diagnosis.
With colleagues as Brown University and Boston University, Veterans Administration (VA) researchers reminded colleagues that chronic inflammation may drive accelerated aging in HIV populations, and that mechanism may affect age at diagnosis of heart failure. They conducted this comparison of age at heart failure diagnosis in veterans with or without HIV after making statistical adjustments for differences in age structure between HIV-positive and negative populations.* Comparisons that do not account for differences in underlying age structures, they argued, are an insufficient gauge of relative age at diagnosis.
The research team based their analysis on data from the Veterans Health Administration. They calculated adjusted median age at diagnosis of HIV-negative veterans by applying statistical weights reflecting the age structure of HIV-positive veterans.*
The analysis involved 5093 veterans with HIV and 1,420,894 without HIV. Median ages of the two groups stood at 58 and 72, 98% and 97% were men, 35% and 79% white, and 56% and 14% black. The HIV-positive and negative groups were similar in proportions with a history of myocardial infarction (21% and 18%), diabetes (37% and 38%), and hypertension (78% and 71%). But the HIV group had higher proportions with chronic kidney disease (28% vs 13%), depression (44% vs 18%), current smoking (54% vs 28%), alcohol use (33% vs 8%), and substance abuse (38% vs 5%). Median left ventricular ejection fraction was 47% in both groups, and median NT-proB-type natriuretic peptide (BNP, a heart failure marker) was 193 pg/mL in the HIV group and 208 pg/mL in the HIV-negative group. Among veterans with HIV, 78% were taking antiretroviral therapy, median viral load stood at 49 copies, and median CD4 count measured 392.
In an unadjusted comparison, median age at heart failure was 72 years in veterans without HIV and 58 in veterans with HIV, a yawning 14-year difference. After adjustment for sex and race, predicted age at heart failure diagnosis shifted slightly to 72 years in HIV-negative veterans and 56 years in HIV-positive veterans. After adjustment for age structure of HIV-positive veterans, the researchers estimated that veterans with HIV were 6 years younger at heart failure diagnosis--58 versus 64 years (P < 0.001).
In subgroups of veterans, those with HIV always got diagnosed with heart failure earlier than those without HIV: for inpatients versus outpatients, 6 versus 7 years earlier; for ejection fraction at or above 45% versus below 45%, 4 versus 6 years earlier; for age at or above 45 versus under 45, 5 versus 2 years earlier; for 2009-2018 versus 2000-2008, 4 versus 8 years earlier; and for diagnosis in the community versus in VA facilities, 5 versus 7 years earlier.
Looking only at veterans with HIV, the researchers estimated an earlier median age at diagnosis for those with a CD4 count at or below 200 versus over 200 (56 versus 60 years), with a viral load above 75 copies versus at or below 75 copies (55 versus 61 years), and for no antiretroviral therapy versus antiretroviral therapy (56 versus 59 years).
Comparing veterans with versus without HIV by age bracket, the researchers found veterans with HIV had a higher heart failure diagnosis rate in every bracket up to age 70: under 30 years, standardized incidence ratio (SIR) 7.4, 95% confidence interval (CI) 3.2 to 11.6; 30 to 39 years old, SIR 3.0, 95% CI 2.5 to 3.5; 40 to 49 years, SIR 1.7, 95% CI 1.6 to 1.8; 50 to 59 years, SIR 1.3, 95% CI 1.2 to 1.3; 60 to 69 years, SIR 1.2, 95% CI 1.1 to 1.2; 70+ years, SIR 1.0, 95% CI 0.9 to 1.1.
The consistently younger ages at diagnosis of heart failure in veterans with versus without HIV, the researchers said, “imply that preventive measures such as screening for heart failure and treatment of risk factors (eg, hypertension, diabetes) may have to occur at an earlier age” in people with HIV. They added that future studies in a non-VA population with a higher proportion of women could extend their findings to a wider HIV group.
*Study statisticians divided the number of veterans within each 1-year age stratum of HIV-positive veterans for each year from 2000 through 2018 by the total number of HIV-positive veterans for the corresponding calendar year.
Reference
1. Erqou S, Jiang L, Lally M, et al. Age at diagnoses of heart failure in veterans living with HIV. 11th International Workshop on HIV & Aging Virtual Meeting, September 30 to October 2, 2020. Abstract 3.
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