icon-    folder.gif   Conference Reports for NATAP  
  Conference on Retroviruses
and Opportunistic Infections
Boston USA
March 8-11, 2020
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Less Coronary Intervention, Higher Mortality in HIV+ People With Acute Coronary Syndrome
  CROI 2020, March 8-11, 2020, Boston
Mark Mascolini
Compared with HIV-negative people discharged from the hospital after acute coronary syndrome, people with HIV had lower rates of coronary intervention, lower rates of prescription filling, and increased short- and long-term mortality and hospital readmission, according to results of a nationwide US retrospective study [1].
Researchers from the University of California, San Francisco and Harvard Medical School noted that people with HIV have greater cardiovascular morbidity and mortality than the general population in the modern antiretroviral era [2]. The investigators noted that this pattern will probably continue as people with HIV live longer with the virus. But it remains unclear how much these differences between the HIV-positive and negative heart disease populations involve pathophysiology versus practice. They conducted this retrospective analysis to sort out reasons for differing postdischarge outcomes in acute coronary syndrome patients with and without HIV.
The researchers created a study group from US nationwide data gathered by Symphony Health, which links inpatient insurance claims, electronic medical records, and outpatient pharmacy claims. This analysis included acute coronary syndrome patients from all 50 states discharged from the hospital between January 2014 and December 2016. People included in the analysis had to be older than 18. The investigators determined who died; they used ICD-9/10 codes to identify inpatient procedures and in-hospital complications. Multivariate logistic regression models estimated odds ratios of primary and secondary outcomes. A separate stratified analysis focused on people who underwent coronary angiography.
The analysis included 1,125,126 adults, 6612 of them with HIV. People with HIV were an average 10 years younger than the HIV-negative group (57.4 versus 67.4 years, P < 0.0001), and the HIV group included a higher proportion of men (71% versus 60%, P < 0.0001). Significantly greater proportions of the HIV group were black or Hispanic, and lower proportions were white (P < 0.0001), although racial/ethnic data were not available for most people.
The HIV group had higher rates of substance abuse (including tobacco use, 62.5% with HIV versus 42.8% without HIV, P < 0.001) and medical comorbidities, including preexisting coronary artery disease (4.69% versus 3.56%, P < 0.001), diabetes, peripheral vascular disease, chronic lung disease, congestive heart failure, valvular disease, liver disease, and kidney disease. While in the hospital, people with HIV had significantly lower rates of left heart catheterization (31.5% versus 33.2%, P < 0.0001) and increased rates of bare metal stents (8.44% versus 6.95%, P = 0.0078).
Logistic regression determined that acute coronary syndrome patients with HIV had independently higher odds of inpatient all-cause mortality (odds ratio 1.29, 95% confidence interval [CI] 1.15 to 1.44, P < 0.0001), 12-month all-cause mortality (OR 1.32, 95% CI 1.22 to 1.44, P < 0.0001), and 30-day hospital readmission (OR 1.18, 95% CI 1.09 to 1.27, P < 0.0001). When researchers limited the analysis to people who had left heart catheterization, inpatient mortality was no longer significantly greater in people with HIV, but the HIV group continued to have significantly greater 12-month mortality (OR 1.25, 95% CI 1.05 to 1.49, P = 0.0116) and 30-day readmission (OR 1.15, 95% CI 1.01 to 1.31, P = 0.0367).
These findings, the investigators suggested, imply that "differing rates of coronary intervention in HIV may explain some of the disparate mortality from acute coronary syndrome." But people with HIV continued to have worse long-term outcomes even after statistical adjustment for coronary intervention.
In the 12 months after hospital discharge, about three quarters of the total group filled a prescription for at least one medication. But people with HIV had significantly lower prescription filling rates for statins, antiplatelets, anticoagulants, beta blockers, nitrates, diuretics, and angiotensin II receptor blockers (P < 0.05 for all).
The postdischarge prescription-filling data suggested to the researchers that people with HIV received "reduced appropriate medical therapy for acute coronary syndrome," which may partly explain their worse long-term outcomes than people without HIV. Overall findings, the authors proposed, "suggest that there remain disparities in the management of acute coronary syndrome in persons living with HIV." They called for "targeted interventions and care strategies to improve the outcomes of HIV-infected individuals hospitalized with acute coronary syndrome."
1. Parks MM, Secemsky EA, Yeh RW, et al. Postdischarge outcomes following acute coronary syndrome in HIV. Conference on Retroviruses and Opportunistic Infections (CROI). March 8-11, 2020. Boston. Abstract 643.
2. Feinstein MJ, Bahiru E, Achenbach C, et al. Patterns of cardiovascular mortality for HIV-infected adults in the United States: 1999 to 2013. Am J Cardiol. 2016;117:214-220.